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FOR OFFICE USE: <br /> APPLICATION MR SANITATION PERMIT (/ <br /> ----------------------------------- Permit No. <br /> (Complete in Triplicate) <br /> This Permit Expires t Year From Date Issued 6/,fl7 <br /> Date Issued --- l. <br /> ____________________________________________________ <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 made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> b Q_ <br /> JOB ADDRESS/LOCATION ._____l'7S�_________S"___�4_IRPMR__ ________.___-__________CENSUS TRACT .. _ ...... <br /> Owner's Name -------M_R(1 _U E L---------[-.F 1.1,CA-V 0------------------------- -------------------Phone ------------------------------------ <br /> Address -------------P..-0-y---- Qx--------7�7------------------------------- --- City _ 44-AICA----------------------------------•------ <br /> Contractor's Name -------0_W_f4E-9--------------------------------------------------------License # ------------------------ Phone -------------_----_-------- <br /> Installation will serve: Residence ❑Apartment House,M Commercial ❑Trailer Court i❑ <br /> Motel ❑Other -------------------------------------------- <br /> Number of living units: - Number of bedrooms .__-_---__.Garbage Grinder ------------ Lot Size ______---_______________________-_-_-._.--. <br /> Water Supply: Public System and name -------------------------------------------------------------------- ------------------------------------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe ❑ 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 I ] Size______________________________________________ Liquid Depth -------------------.__---- 0 <br /> Capacity -------------------- Type -------------------- Material---------------------- No. Compartments -----------------.--... <br /> Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ---------------*....... <br /> LEACHING LINE [ ] No. of Lines ___________________ Length of each line---------------------------- Total Length ---------—................ <br /> 'D' Box ------------ Type Filter Material ____________________Depth Filter Material --------------------.-...................... <br /> Distance to nearest: Well ________________________ Foundation ------------------------ Property Line ........................ <br /> SEEPAGE PIT [ J Depth -----_____---------- Diameter _______________ Number _-------------------------- Rock Filled Yes ❑ No i❑ <br /> Water Table Depth ----------------- ------------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well ________________________________________Foundation _________-____-. --- Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ____________________________________________ Date ----------------------------------) <br /> SepticTank (Specify Requirements) ---------------------------------------------------------------------------------- f---------------------7f,.------------------ --------- <br /> Disposal Field (Specify Requirements) ----- J� -------- 1� -------------------�Z------"`--------- l---------mlxf ------ <br /> LEAct��- �t_nt ---------A_M—niP_w -€i+--i------ <br /> ------------------------------------------------------------------ ------------------------------------ ---------------------------- - ---------------------------------------------------- --------- <br /> (Dravy''existing and required addition on reverse side) <br /> 1 hereby certify that I have prepared this;application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, State Laws, and Rulei and Regulations of the San Joaquin Local Health District. Home owner or licen- <br /> sed agents signature certifies the following: <br /> "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner <br /> as to become su lett Work 's Comp gtloa laws of California." <br /> Signed ------------------------------ Owner <br /> By ------------------------------------------------------------------------------------------------------- Title ---------------------------------------------------------------- ------ <br /> (If other than owner) _ <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -T1-K-6`----------rjl K----------------------------------------------------------------- DATE ------- - �'�------ /------------ <br /> BUILDING PERMIT ISSUED -------- ----- -- DATE ------------- ------------------------_-- <br /> ADDITIONAL COMMENTSlT`----�LS�N�----------------------------------------------------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------- --------- <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------•---- <br /> ---------------------------------- <br /> ------ - - - - - - - - - - --------------------------------------------- <br /> --------- <br /> - - -- - <br /> ----------------------------------------------- ----- ----- ---- - ---- ----- -- -- -- - ----- <br /> Final Inspection by: -- 6 ---------------------------------------Date ----`�l <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />