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rurc urri�e sae: APPLICATION FOR SANITATION PERMIT f�JJ( <br /> ........ . .................... (Complete in Triplicate) 1 Permit No. ."l.y__g __.. <br /> J <br /> -__---.----_--__--._-.---- This Permit Expires 1 Year From Date Issued 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 ma/dee in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> 4 JOB ADDRESS/LOCATION ._--.L7../_`�L_-_SIJ. V-ISTOR�----Rb--_..__.--------._CENSUS TRACT <br /> cc <br /> Owner's Name ...........41-vl-N-------- p----- - ------ ---------- ---- ------Phone ------------------------ -- <br /> Address -----/45?_2_j-------.S .-------V ..... ...._ City --- --------------- <br /> Contractor's Name ----- - - -- - - --- - ---------------------- <br /> License # ---------------- ---. Phone -------------- - <br /> Installation will serve: Residence rtment House❑ Commercial ❑Trailer Court I] <br /> ./ Motel ❑Other---- - ----------------------- - <br /> Number of living units:-----f--_ Number of bedrooms .3-------Garbage Grindeiy.C--S.- Lot Size .09 _Et4C __---___- <br /> Water Supply: Public System and name .--------------------------------------------------------- -------------------Private <br /> Character of soil to a depth of 3 feet: Sand❑ Sil ❑ Clay ❑ Peat❑ Sandy Loam ❑ , Clay,Loam <br /> Hardpan dobe o Fill Materl6l yij=If q Y\typ ^'J . <br /> (Plot plan, showing size of lot, location of system in relation to: wells, buildings, etc. must be placed on reverse side.) <br /> PACKAISE TREATMENT SEPTIC�TANK 9�p Size_TX (lic sewer is within 2Deptih ,) .r <br /> NEW INSTALLATION: (No septic tank or seeps it permitted if pub f <br /> [ ] 7_ Q__X 6 __t ----- Liquid Depth 0�7.. ... <br /> Capacity f?..Q-c)----- Type PE _$:1-MaterialCLN KRVtE_lo. Compartments ---------- <br /> \ <br /> _ _ <br /> istance to nearest: Well2v-_____r'�_-__.._.Foundation ----A?.!_r-_._ Prop. Line <br /> r <br /> ... O r <br /> � LEACHING LINE [ N __________ <br /> o. of Lines _______ ______ Length of each line.--__7..�-_..._.______ Total Length ._.f.g <br /> 'D' Bcxrr:5_ Type Filter Material )ROCK---_Depth Filter Material __L ------------------------------........ <br /> . .� <br /> Distance to nearest: Well --_A9 '--------- _.. Foundation 1�. !� ___ Property Line <br /> r -- ------ - ----- <br /> SEEPAGE PIT Depth --1 ---r------ <br /> Diameter . !f_ ___ Number. _ Rock Filled • Yes �� ❑ <br /> Water Table Depth --_ p.-._-_--.._. _.--------- ---------- Size -- ._ _ <br /> _.__ - r <br /> Distance to nearest: Well -/ �............ .._.- _-Foundation f�----___.-. Prop„ <br /> _ _ —--------- 2-- <br /> .-_J`-__-.-------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ---------------------------------------.---- Date ----------------------------------) <br /> Septic Tank (Specify Requirements) ----- ----------------------. --------------------------------------------­------._:..---------------•�*^--'------- <br /> Disposal Field (Specify Requirements) -------------------------- ---------- ----------------------- ..--------------------------------------"A---=------------------------ <br /> -- <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 performa e f t e work for which this permit is issued, 1 shall not employ any person in such manner <br /> as to beco [�,ub�je�ct�to Work a s m ' n laws of California.” <br /> Signed - - w�- = "-------- ----- - ------------- -----------------------------.. Owner <br /> By - ------------------------------- --------_.-__--- -----------------TI-r-0---- Title ----- - ---_ ------------(If other than owner) <br /> FOR DEPARTMENT USE ONLY // // <br /> APPLICATION ACCEPTED BY - J pp I- a----------------- --------------- - --- - ----------------. DATE -----/-/-.6----- 0------- <br /> BUILDING PERMIT ISSUED - - -- ----------------------------------------------------------------------- ---------------_------.DATE ------------------------------------------ <br /> ADDIJIONAL COMMENTS -----_ - <br /> ----------------------------------------- -----------._...- - --------------------------------------- ------------ ------------- <br /> Ae <br /> ----------­--- - -- -- --- -- -`--- -------------- <br /> ------------------------------- I - - - - - - <br /> ------------------------------------- - - - ----- --- - --- ----- ------ <br /> - } <br /> ` Final Inspection by: ---- -- - ---- ------ ---- -- - - -- -------- ----------------------Date ----f-- -=--- -----•---- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />