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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT - / <br />................ J..... < Permit No. . <br /> .:- (Complete in Triplicate) <br /> . ............................... ...... -=-- <br /> I This Permit Expires 1 Year From Date issued Date Issued .. <br /> Application is hereby made to the SonJoaquinLocal Health District for a permit to construct and install the work herein j <br /> described. This application is made i6i�6rmolianceiwith County Ordinance No. 544 and existing Rules and Regulations. <br /> I <br /> JOB ADDRESS/LOCATON ... ® .. ,. .4'��� ................ <br /> ...........:............CENSUS TRACT .......................... <br /> Owner's Name 41t............a �f ............ Phone <br /> --------------•-•----••..._..:....... ••••-•..._............ ............. <br /> f <br /> Address -- .......- �.-�!Cir �................................................ <br /> . City � <br /> .......... --------•----•-•--.........---... <br /> Contractor's Name .../ef % -_....License # 12VJ:9, 3?-. Phone ...... <br /> Installation will serve: Resident&A Apartment House C❑ Commercial []Trailer Court 0 <br /> i <br /> Motel ❑Other ........................._-----_----- .. <br /> Number of living units:..- .... Number!of bedrooms ...Z------ Grinder lVe... Lot Size fi7A-41-r.. ............... <br /> r--__ ��le 64e f41 f, .'.................................. ....... <br /> Water Supply: Public System and name ..a&4 ....Private C3 <br /> Character of soil to a depth of 3 feet: Sand[3 .Silt❑ Clay 0 Peat❑ Sandy Loom ❑ Clay Loam �] <br /> Hardpan ❑ Adobe fX Fill Material _........... If yes,type ... ............... <br /> (Plot plan, showing size yof 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 [ J SEPTIC TANK] ] Size............ ................................... Liquid Depth .......................... <br /> Capacity .................... Type .................... Material..................-..-..�No. Compartments ...................... <br /> Distance to nearest: Well .........................!..........Foundatibn -_. ... ...... Prop. Line ...................... 0 <br /> 4 LEACHING LINE [ ] No. of Lines ........................ Length of each line----- ......... -___....... Total Length ....-_......__.............. <br /> I i <br /> 'b' Box ------------ Type Filter Material ....................Depth Filter Material ......-_........I............_.....__.- -•- <br /> Distance to nearest: Well ........................ Foundation ........................ Property Line .................... <br /> SEEPAGE PIT [ ) Depth .................... Diameter .-:............. plumber ....-------------._ -----._. hock Filled Yes ❑ No � <br /> Nat t x <br /> l:.Table <br /> _ - � - - -----.- o0 <br /> Distance to nearest:,Well ........................................Foundation ......- Prop. Line ................... 1 <br /> REPAIR/ADDITION(Prey. Sanitation Permit,q <br /> --•-----•--•--•-----------------------•--... Date ._..----•---.._........----..... I <br /> Septic Tank (Specify Requirements). •---------- - -----------------------............ .. .... ....................... .. .................. <br /> Disposal Field (Specify Requir ment .. �----� 1 - !�-��` /_ _' Jl�• `'.-- ' <br /> ----------- --------------`---------.-•--•------------ <br /> ----------------------- -----------------•--••----__. ------------------------------------- .....- <br /> (Drdw existing and required addition on reverse side) , <br /> 1 hereby certify that 1 have prepared tiiisjapplication and that'theNwork will be 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 [icon- <br /> sed agents signature certifies the following: <br /> r "I certify that in the performance of the work for which this permit is i sued, 1 shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> f i <br /> r <br /> Signed ............. ..... .... ........------- Owner <br /> sy ......... ..... .. - A - . Title _ C " :...............- .---.---..-- --- — <br /> 4 <br /> i "IiY E <br /> other than owner) <br /> 1 EPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY •--...� .-. DATE �• ---•--------- <br /> BUILDING PERMIT ISSUED .......... ' -----------..............................................-....-:..:........ -DATA: . .. .... ..... ._.............. <br /> ADDITIONAL COM ENT ....-.-. . ... . ........................ . .. . <br /> ................... t. ....... . ._ . ..... ..... .................... ... . ...:.. ................. ...............• ----------­------ <br /> - <br /> r <br /> ........................... <br /> ..................... ....... ... . . ...........—---------- --------......-•-------...-•-----•._......-............. <br /> '. -- ...........................................•--•--•-----._..................... -----.. ...._- <br /> Final inspection by; �J4 <br /> Date ....... <br /> JQUIN LOCAL HEALTH DISTRICT rdtb <br /> 11 9A . 7/72 3 ,4 <br />