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FOR OFFICE USE: APPLICATION FOR SANITATION PERMt, <br /> ...... .. ._. Permit No. <br /> -- - - -- (Complete in Triplicate) <br /> ......-. �_�� <br /> Date Issued .J..............i_73.. <br /> .... <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. T! is application is made in cog lia ce with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/L CA�TIOyN� ...... .... CENSUS TRACT .......................... <br /> 1/-/...{ . . . - -�ZS. G................................_............. ................Phone .................................... <br /> Owner's Name J.. (.�- --- - /� <br /> � t <br /> 1 s Cif c� <br /> Address _..........-- �-�-,1.�-...-�.�.!_n... ��`.�... y .:�1��[.� ......................................................... <br /> Contractor's Name .. ..L.k'-...._U�-[qt:< ......................................._......License Phone `. fi..'........ . ......e' <br /> Installation will serve: Residencepartment House C1 Commercial ❑Trailer Court ❑ <br /> Motel ❑ Other ..................------ ---- ....-------.- <br /> Number of living units:........./Number of bedrooms ; . --..Garbage Grinderv/. Lot Size .. � -.X. �L--......... <br /> Water Supply: Public System and name ...................----..-.-_....._.......-......----...:- -.-..--.... -..........................---.Private <br /> Character of soil to a depth of 3 feet: Sand 0 Silt❑ Clay Peat ❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe 11 Materigk -J... 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: INo septic tank or seepage it permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK{ � Sizes...-.. --fit/---- - Liquid Depth .. � �-.----- <br /> 1 <br /> Capacity A1�----- Type2L.�G1�. oterial--n h u< No. Compartments ....2:::�.......... <br /> Distance to nearest: Well .......5T. .....................Foundation ...-yl�-......... Prop. Line .JS-�.....-.... <br /> LEACHING LINE [.�No. of Lines .......1-------------- Length of�ach line...,`ev........-.-... Total Length .1 -'------------- <br /> / r i <br /> 'D' Box /f�0..... Type Filter Material --9.G�..--.Depth Filter Material .-.ll�................................... Z <br /> 11 <br /> Distance to nearest: Well ..I�---.------ Foundation .14 ............. Property Line <br /> .......... <br /> SEEPAGE PIT [a�—Depth ........ Diameter 3j� a Number ....J................... Rock Filled Yes Q/IQo C3 <br /> Water Table Depth ........... ....... ...-........................Rock Size <br /> Distance to nearest: Well ..-..�.. ....................... Foundation .--/Q-........ Prop. Lina .../ ./------ <br /> REPAIR/ADDITION(Prey. Sanitation Permit# ............................................ Date ..................................) <br /> 0 <br /> Septic Tank (Specify Requirements) ----.-----------------------------------------------------------.-------------------------------------------.------.-----_........-........ <br /> Disposal Field (Specify Requirements) -"-' "-- . -- ...� <br /> ._.._........-...--- --..-...._.........._......................................................--....._--............_.........--..................----...--'----.... . <br /> ----._... ....................................._........................ .............................................. <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that 1 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, 1 shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed .... . . _ Owner J <br /> By . - l hrS Q......... .... ... Title ....... .. L_' '"L _. ....... <br /> (If other than o er <br /> FO$D ARTMENT ONLY <br /> APPLICATION ACCEPTED DATE -.�_. . -. 3 <br /> ............... <br /> BUILDINGPERMIT ISSUED ...........-- . .-........................................................... ... . .-_............-- DATE .. ._._....._-.-.... - .- .......... <br /> ADDITIONAL COMMENTS ........... .............................-...........- ------ ...................................................-..._.................................... <br /> . <br /> - ................_.... --------------- ------------------ ........_......--..... . ..... . ....-. <br /> ............... <br /> --------------- <br /> Final Ins ection b _ ................._.....-........Date -.'..-.....-.-....-__.. ...... -- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br />