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i <br /> FOR QMCE USE- <br /> APPLICATION FOR SANITATION PERMIT <br /> -------- -------------------------- Permit No. '71--_1_&7--. <br /> (Complete in Triplicate) I <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 application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations. <br /> JOB ADDRESS/LOCATION ,& Q0------5----- -------- -------------------------------CENSUS TRACT -------- -------- <br /> ----- <br /> Owner's Name .- - �1 ----- - 2.3 , 1' _-/--0_ /4- <br /> �f ��/�J Phone <br /> .- .�- ��¢-------- --------------------- City - - '_ r/-------------------------- <br /> Address -- - -may-- -- ---- - ----------------- - � >� _ � ------------------ <br /> Contractor's Name .-- � � 7f �L_ License # � -- Phone �tS . <br /> Installation will serve: Residence Apartment House-[] Commercial❑Trailer Court i❑ <br /> Motel ❑Other ------- ------------------------- <br /> Number of living units:..- t----- Number of bedrooms -_�7------Garbage Grinder ------------ Lot Size _A1Ji& <br /> Water Supply: Public System and name -------------------------------------------------------------------------------------------------•-------------Private ❑ i <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 ithin 200 feet,) <br /> PACKAGE TREATMENT ] ] SEPTIC TANK:( ] Size--- :---__--___----------------_--- ------ Liquid Depth .--- ----.-----------._--- <br /> .Capacity --------------------- Type ------------------ Material---------------------- N Compartments ---------------------- <br /> Distance <br /> ---------- -•---- <br /> 4 <br /> Distance to nearest:'Well --_-------------- -----------------Foundation ----.--- ------------ Prop. Line --_---------:......... <br /> LEACHING LINE [ ] No. of Lines ----------------- g - Total Length <br /> - Length f each line --------------- -----------------•-•-------< <br /> 'D' Box ------------ Type Filter Material --------------------Depth Filter terial --------------------.---------------------- <br /> Distpnce to,nearest: Well --------------- -------- Foundation _-___-_____--- ------- Property Line -_---_--------. ------ <br /> SEEPAGE PIT [ ] 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 /> Septic Tank (Specify Requirements) --------------------------------- --- <br /> ---------------------------- <br /> ---- -----. -------------------------- <br /> Disposal Field (Specify Requirements) -_ -�---��--_-- 41slC---------- --- --------------- <br /> �5/!/tl5y_ <br /> f ° ------------------------------ ----- <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 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 become subject to Workman's Compensation laws of California." <br /> Signed -------- -------------,--- ----- <br /> --- Owner <br /> By ------- -� Title ------- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ---- --�- t R`0' - <br /> ------------------------------------- ---------------------------------- DATE r-./ - ------ <br /> BUILDING PERMIT ISSUED .--..--.---_f -_ <br /> -- --------------------------------------------------->--------------DATE --------------------- ----------------- <br /> ADDITIONALCOMMENTS --------------- -------- ------------------------------------------------- ----- -- --------------------------------------- ------------- <br /> --------------------------------------- --- ---- -- ------------------ - ---------------------------- - <br /> - ----------------------------------- - -- <br /> w -- -- - )-,- <br /> Final Inspection by:: -G��-------- ----- /� Date --- --� f---` � { <br /> '"+r�` -=--------------- -- -------- -- to <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> i <br /> E. H. 9 1-'68 Rev. 5M <br />