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FOR OFFICE USE: <br /> APPLICATION <br /> _ 4 FOR SANITATION PERMIT - <br /> ------ -•- -- Permit Na. .._7 -33.6 <br /> . lComplete In Triplicate) <br /> a <br /> A <br /> - ......_ Date Issued . -/S_.76 <br /> This Permit Expires if Year From Date Issued ....... <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein <br /> described. This application is m`a'de in compliance with County Ordinance No. 5.49 and existing Rules and Regulations. <br /> JOB ADDRESS/LOCAs N �.'.... <br /> �•-• � "­-.A'<..'._1..... ...............CENSUS TRACT .......................... <br /> Owner's Name _.._.. . • -• -------------------­- ----------------- ..............Phone <br /> Address .. ...... . .. __. .�__�.�... ._.__... , <br /> / City ------------------------- <br /> •-------------- <br /> Contractor's Name - -- ----- License ila` _f..�...... ....... Phone <br /> Installation will serve: Residence - Apartment House Commercial[-Traller Court 0 <br /> Motel ❑Other.......................... . ...... <br /> Number of living units:_.. ------ Number of bedrooms ..4...... <br /> Garbage Grinder Lot Size <br /> Water Supply: Public System and name .................................................. .......Private <br /> Character of soil to a depth of 3 feet: Sand 0 Silt 0 Clay ❑ Peat.[] Sandy Loam e Clay'Loam ❑ <br /> I <br /> Hardpan 0 Adobe 0 Fill Material ............ if yes,type............... ............ <br /> (Plot plan, showing size of lot, location of system In relation to wells, buildings, etc. must be placed on reverse side.! <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK f ... ..._........_ Liquid Depth <br /> ...Size- -•. ....................... <br /> Capacity .................... Type --- ---------------- Material.......... No. Compartments ..:_..._.._ ..........9 <br /> Distance.to nearest: Well ----------------_ .................Foundation.............I......... Prop. Line ...................... 0 <br /> LEACHING LINE [ No. of Lines ........................ Length of each line............................ Total Length <br /> Y 'D' Box . Type Filter Material .Qepth Filter Material <br /> Distance to nearest: Well .....................--- Foundation Property Line ........................�y <br /> SEEPAGE PIT [ ( Depth -------------------- Diameter ..........:..... Number -------- ................... Rock Filled Yes [] No 0, <br /> { <br /> Water Table Depth ---------••-•-•--•..................... ........Rock Size ................•. •-•-••---••- <br /> Distance to nearest: Well ........................................Foundation ............... Prop. Line .....•................ <br /> REPAIR/ADDITION(Prev. Sanitation Permit .__...._...... Date Id <br /> ' ...:.-•-----•--- ---_--------� <br /> Septic Tank (Specify Requirements) ...........:.........................•...---....__......--•- • -•--.. <br /> Disposal Field (Specify Requirements) ____ •�,ds�___ --- __._• __._.... .. .,:.� <br /> --------------------- <br /> S� <br /> ----- ------------ --------------- ----- ---•-----------. .................. --•-•.... ----------- <br /> (Draw existing and required addition on reverse side} <br /> I :hereby certify that I have prepared this application and that the work will rbe done in accordance with San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health,District. Home owner or licen- <br /> sed agents signature certifies the following: il <br /> "I certify that in the performance of the world for"which this permit is issued, 1 shall not employ any person in such manner <br /> as to become subject to Workman's Compensation.laws of California.,, <br /> Signed ----------_----------------- - ........... Owner <br /> By <br /> . <br /> ---(If other than owner) -- -•-----•-- <br /> '-'-" <br /> FOR DEPA TMLNT USE ONLY <br /> APPLICATION ACCEPTED BY �....,�_ .{? _.. DATE + r <br /> 76 <br /> --- ..._. <br /> BUILDING PERMIT ISSUED ----- DATE <br /> ADDITIONAL COMMENTS ..------------••-- -----. _ -_-- <br /> ------------- _.........--•-- •------•--------._. - -- .....------..__._...._. <br /> -----------------------------•----•......-:-----=----._---.-.-...._.--------------------------------------- --------.-..._.__.._....._.._....-....__._...._...... <br /> final inspection by: .. •- -------------•---- -----•.._..Date .. ....c.. <br /> : :::�:::: r.. ::: ` .::::::::::::::::::_ <br /> EH 13 2I4 1-68 f3.ev. 5M N AQUIN LOCAL HEALTH DISTRICT 8 <br /> /7!a 3M <br />