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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> Permit No. <br /> ......................................................... (Complete in Triplicate) <br /> Date Issued ------- <br /> _ ------------ This Permit Expires 1 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 application6is ac irycom li ryy� gt,yt.Ordirnr,��l54d,gsting Rules and Regulations: <br /> y - _ CENSUS TRACT .. .JOB ADDRESS/LOCATI 'r ._. . . --•• '.-.--------------...... ...... <br /> gLtal pp ......Phone <br /> Owner's Name <br /> .. <br /> pl rrtuo �' <br /> Address _....;_... I ..... - - � ............. City ••---------------b --/p --.�- <br /> Contracto'r's Name - --��ZGI/ 'G'• License # Phone <br /> 10 <br /> J-... <br /> ..- - <br /> Installation will serve: Residence ❑Apartment House Commercial'❑Trailer Court 0 <br /> r e iii Motel ❑ Other------ ••---- <br /> i <br /> ``^Nurn bei of''livm unity............. Number of bedrooms ............Garbage Grinder .... Lot Size .--------------------•••---•-•-•- -•-------- <br /> Water Supply: P6blic System and name .................. ... Private <br /> Character of soil to a depth of 3 feet: Sand b Silt[] Clay ❑ Peat C) Sandy Loam ❑ Clay Loam <br /> Hardpan ❑ Adobe ❑ Fill Material ............ If yes,type ............................ t <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 its available <br /> ailable within 200 feet,j �r <br /> SEPTIC TANK Size.__..--_--5--- - / Liquid Depth ......�/�. --.... <br /> PACKAGE TREATMENT [ ] [ l ... <br /> 2/--•, <br /> Capacity, pW...•.,-- Type ---- ........ ••--.• Material-.�+�'�. No.�Compartments <br /> t <br /> Distance to nearest:-Well ....................Foundation .../ ............ Prop. Line ......_.��.._.--_.-_ �1 <br /> LEACHING LINE [ ] fo: of Lines .....--.-1_._..�.-.� Length of each line...__ /.Cf!]-_. -- ...... Total Length ....- ............... <br /> i, <br /> D' Box •----------- Type Filter.Material -.� - ..-Depth Filter Material .... > _... <br /> N O <br /> Distance to nearest: Well— -- <br /> �_�--------- Foundation ------------------------ Property Line ..................... <br /> SEEPAGE PIT [ J Depth _.__. .. ..... - Dai meter .3- ........ Number ....-......r.............. Rock Filled Yes No <br /> Water Table Depth Rock Size --------- -------.�_... ._------ <br /> Distance to.nearest: Well .___-....1jOV..................... ... -------- Prop. Line .... ... ........... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# .......... ..........................= _ Date ....._.:------------------------- <br /> ----••------••-•...................•------ -•------- ... <br /> Septic Tank (Specify Requirements) ..`_: _---------.......�i_�..-~_� ....._.-1.�..... `n <br /> Disposal Field (Specify Requirements) ... • - •• _.......... \� <br /> .........AW <br /> ------- ------------------------------------------_ .............................-. ...........---••-. --- .----...... ............................................ <br /> �- - <br /> ------ - -•--•----. . . -I- - ------------ --------•----•--•------....-- --------------------------------------------------- ------. <br /> (Draw existing and required addition ori �ever4 side) <br /> I hereby certify that I have prepared this app iia ion and that the work will be done in accordance with San Joaquin <br /> County Ordinances, State Laws, andiRules and Regulations of the Son Joaquin Local Health District. Home owner or licen- <br /> r sed agents signature certifies the following: --- <br /> "1 certify that in the performance of the work for which this permit is issued, { shall not employ any person in such manner <br /> as to eco- <br /> bje t fo Workman's C mpensation laws of Califomia." <br /> Signed -4--.1, ..... ..................... Owner <br /> Title -------------- ......- ----- ------------ <br /> By ------ <br /> (if t er than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ... ✓ ------------------.....;.-- ..-. DATE..-...5 -' -....... <br /> BUILDING PERMIT ISSUED ................ ...;.w.,AATE 2 _.,...__....`..-....---...... <br /> --- -- -- -- - ; , . <br /> ADDITIONAL COMMENTS --------------- ...... -------------- <br /> ` :...._...._. <br /> ..................... ........ ..._.-__-...F...-__-.-....--...-..-...........-__..._---.._._.--.............------..--...._._..........-----................__......_.__--....--........_._. -_.---... <br /> ................................. <br /> . tf1--.J.'�_-_ e_.. ............................................•-•••..__------------------- --------• - - __ <br /> 1�%•.r� u.-,. Date <br /> - ----- • -----• .....Final lnspection.byo ..-_._-.... . .- <br /> - SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E.H. 9 1-'68 Rev. 5M <br />