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11 <br /> FOR OFFICE,LW <br /> p IMITATION PERMIT <br /> ---------------------- --- ----•- -- -- --- APPLICATION FOR SANITATION Permit o. �_ <br /> (Complete ir�►frjiolicate) <br /> --------- --------------------------- ------ . <br /> This Permit Expires 1 Year From Date Issued Date 1 ed �_�_-7. <br /> Application is hereby made to the San Joaquin Local Health District for�,49 <br /> permit to stall the work herein <br /> described. This application is made in compliance with ounty OrdinanNo. 5 a existin Rules and Regulations: <br /> ,lam f <br /> JOB ADDRESS/LOCATION ---- = --��l-�----------------------- ------ - /`-�� [ , S 7,. <br /> / CE USTRACT --- --- <br /> Owner's Name C_ .fi t -c � _�<__ �- - - hone _� ------- <br /> - <br /> a <br /> ---- --- <br /> 9L-[�l- t�[ c{ � � City <br /> --/11 ` --- ------ -�/ - <br /> Address <br /> Contractor's Name -- <br /> #�p(�€-;f. - Phone <br /> Installation will serve: Reside ce partment House❑ Commercial -❑Trailer Court i❑ <br /> Motel ❑Other ------------------------------------------ <br /> Number of living units: --- Number of bedrooms _—'L---Garbage Grinder .----C-- Lot Size -i <br /> Water Supply: Public System and name ---------------------------------------------------------------------------------------------------------------Private _ <br /> Character of soi I to a depth of 3 feet: Sand'❑ Silt❑ Clay [A Peat❑ Sandy Loam ❑ Clay Loam <br /> o <br /> '1 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'[ ] Size------------------------------------------------ Liquid Depth __________________________ d <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 Depth - Diameter ---------------- Number ---------------------------- Rock Filled Yes No <br /> Water Table Depth ------------------------------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well ________________________________________Foundation -------------------- Prop.�Line _._.____..________---_ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# --------------------------------------------- Date ---------_------------------------1, +" . <br /> Septic Tank (Specify Requirements) --------------------------- -- <br /> -------- ------------------- <br /> Disposal Fied (Specify Requirements) _-A _ ! ______.�_(�__U :_ . <br /> ---�-6`x 3 {------ ------------------------------------------------- <br /> ------- <br /> --------------------------------------------------------------------------- - -----------------------:- ----------.-. ------------------------------- <br /> (Draw existing an required addition on reverse side) <br /> I'hereby certify that I have prepared this application and that the worle'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 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 becom su Iect to Workman's Compensation laws of California." <br /> Signed . Owner <br /> BY ----------------------- - -------------------------------------------------- Title . <br /> ------------------- ------ -------------------------- <br /> (If other than owner) <br /> ` .FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -------------------------------------------------------------- DATE '_i?1_ ------------- <br /> BUILDING PERMIT ISSUED _____________________ <br /> --------------------------- ---- -- --------- - ------------------------DATE ----------------------- -- O- ---- ----- <br /> ADDITIONALCOMMENTS ----- --------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ----------------•------------------------------------------------------------------------------------------------------------------------•---------------•------------------- <br /> ------------------ <br /> --=-------- -- ------------------- -- ------ - -------------------------------1'--------------------------------------- --------- <br /> Final inspection by: ---------------------------------------------------------- -------- - Date 0.--` G --- � -- _ <br /> J/ ` SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> f . 4 <br /> E. H. 9 1-;b8 Rev. 5M „ <br /> v <br />