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M <br /> FOR OFFICE USES APPLICATION FOR SANITATION PERMIT <br /> ------------ ------------------------------------------ (Complete in Triplicate) Permit No. <br /> ---------------------- <br /> Date Issued <br /> _-_ This Permit Expires 1 Year From Date Issued <br /> t ' <br /> Application is hereby made to the San Joaquin Local Health District for a per to construct and install the work herein i <br /> described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> .�. i%P s <br /> r I------ <br /> JOB ADDRESS/LOCATION ._'_ 1-------- ------ ------ ���_���---- -------- - • (o- --CENSUS TRACT ---�_'-�_ <br /> — <br /> Owner's Name -------JO�------- M-�?�Et --a--------------------------�,---;--------- '--------Phone S45'=_3_3.t$7------- <br /> .. <br /> ------ <br /> �y r ---- <br /> Address _ ,1.1 5 �-- ...... <br /> --"- R� -----------•--- CityA1-* �:" <br /> Contractor's Name <br /> ------;5F—?T1C- T NS License# <br /> Phone ------------------------------ <br /> Installation will serve: Residence 2�<Partment House❑ Commercial :❑Trailer Court ❑ <br /> Motel ❑ Other -------------------------------------------- <br /> Number of living units.- ------- Number of bedrooms __..Garbage Grinder (1f ___- Lot Size --1� CAA- ---• <br /> Water Supply: Public S stem.and"nam --------------------------- __ _ _ ____________ nvat [� <br /> P <br /> y t .- e <br /> Character of soil to a depth of 3 feet: ' -San❑`"Silt fl— Clay Peat❑ Sandy Loam j[�Clay Loam ❑ <br /> � s <br /> Hardpan ❑ . AdobeQFull Material IfYes,type _-._.."_---.-•-------------- <br /> 1 7 <br /> (Plot plan, showing size of lot, location of system Lin relation wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No se tic <br /> p seepage pit perm�itte if public sewer fis available within 200 feet,) <br /> ,tank or <br /> PACKAGE TREATMENT [ ] SEPTIC TANK'[ j _ Size-- ---------------- 'I ---------------- Liquid Depth -------------------------- <br /> Capacity ---- �------------- Type <br /> Ca <br /> Materiai!---------------------- No. Compartments <br /> P rd <br /> Distance to nearest: Well '----------- ------ -----------`-Foundation ---------------- ----- Prop. Line ---------------------- ff <br /> 9 W <br /> LEACHING LINE . [ ] No. of Lines _ _ Len #h�--of edc�lt-""IAii�e------ --------------------- Tota! Length .-------------------------=• , <br /> 'D Box -__--. _--- Type Filter Material __, -------- Dep#h Filter Material _-- _ ____-____ ' <br /> Distance to nearest: We ___ `-----__ � ^Foundation ------------------------ Property Line --------- -------------- <br /> } ''I ` Rock Filled Yes ❑ No I❑ <br /> SEEPAGE PIT [ .....� Depth -- L ------ Diameter".�---- Nui +ber <br /> Water Tdible--#De'pth-7----------`- --- -- -Rock Size - --------------------------- <br /> Distance to nearest: Well -------_______ ______ <br /> ---------------Foundations ------------ ---- Prop. Line -----------•-•-------- <br /> REPAIR/ADDITION{Prev. Sanitation Permit# L � jSr(-11f.'Date ____ ___________________) <br /> _.�. ------------ <br /> Septic Tank (Specify Requirements) ___ �_ . . - ��`'_.-;5y-Sr M---'-`---------_fz_�Q-----���- <br /> ' <br /> Disposal Field`(Specify� Requirements)n-_�c-kl-.•------PREFA-�---yi c �rT"K_ -TAN M� ---EW"x <br /> ` <br /> -----��--�------70--. X q�f -----�PXE------nEAo4----- LJ rVr=S-:Jj----I---------------------------- ------------------------------ <br /> --- <br /> = ---------------- - ------------------� " <br /> F 1 r. ;jDfaw existing-and-required addition on reverse side), <br /> 1 hereby certify thavil have prepared this application 'and,that the work will-be ;done in accordance with San Joaquin <br /> County Ordinances, State Laws, and Mules and Regulations'of the San,Joaquin Local Health District. Home owner or licen- <br /> sed agents signature certifies theAllawing: ' <br /> "I certify that in the performance ofithe work for which this permit is issued, l shall not employ any person in such manner <br /> as to become subject-fo Workman's Compensation laws of California." ') <br /> Signeo_,_._ f ---------------­- Owner <br /> ITi-Ra- Title ----- -------------BY ----------------- <br /> (If ­71 <br /> i}t <br /> other than own "' = V <br /> FOR DEPARTMENT USE-ONLY t' <br /> ACCEPTED ,BY ---------�1�-- `--------------------------------------------------------------- -------- DATE Z 17-.. --------------- <br /> APPLICATION <br /> Bl7[LDING PERMIT-ISSUEDr .------------------------------------------------------------ _' - DATE _ ------------ = -- <br /> - -------- <br /> ADDITIONAL COMMENTS �, ` �` ° --------------------------------- - ---------- <br /> ---- -- --- --------- <br /> ---------- <br /> -�_.. � _.w <br /> _ w <br /> --------------------- <br /> ------------------------- -- -- - -- -- -- -- ------ -- -- -- - - --------- -----------------------------------------------Dat----- -- <br /> Final Inspection <br /> ----------- e -- . <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'b8 Rev. 5M <br />