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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT •7 " <br /> Permit No. <br /> (Complete in Triplicate) <br /> p <br /> Date Issued <br /> --------------------------___-____---------------- This Permit Expires 1 Year From Date Issued <br /> k( {{i <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/LOCATIONT/_` /TCENSUS TRACT -------------------- . <br /> IV <br /> Owner's Name AIIMX*14/�?-----pe---, _k� _P 1--- ---------------------------- T-- Phone <br /> Address f 4015r"_ - 4141--- fj City �_���/�'�/✓ <br /> ----------------------------------- <br /> Contractor's Name .________-License. -5�3��___ Phone <br /> -Installation will will serve: Residence 9<Partr ent,House,,D-Commercial-❑Trailer Court i❑ <br /> s , <br /> Motel ❑ Other .-----------------1 r------------ <br /> Number of living units;---/---_ Number of bedrooms __'3-.,-'Garbage Grinder _____._____ Lot Size -._-- --91e��4�............. <br /> Water Supply; Public System and name ______________________ _ ---N �- �-- ___________________Private [ - <br /> Character of sail to a depth of 3 feet: Sand'❑ Silt❑ Cla ❑ -"Peat E] Sandy Loam Clay Loam [ � <br /> :-Hardpan ❑ Adobe ❑ :Fill Mdteriai ------------ If yes, type _____-___.________________ I <br /> (Plot plan, showing size of lot, location'iof system in relation to wells,!buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit-perrQitted`If-pubfics.9wer is available within 200 feet,) <br /> PACKAGE TREATMENT SEPTIC TANK' e� . - `* _ ?/r { <br /> C Size -X -----__-. - Liquid'Deptli _r' <br /> Capacity Type,V--7? __ Material_0 No. Compartments <br /> ­Disiance to nearest:`"Well' -Foundation Line __ _________ <br /> LEACHING LINE [11-11"No o'Liries ql <br /> D' Box - ��__ <br /> Type-Filter�%Mate is oG--! line_��i�_-_______.______ Total Length ,��____________________ <br /> Length of ea <br /> �l yp / -_ _-__-_.I?epth Filter Material f ------------------------------------ <br /> 70 <br /> _________-_ ___ <br /> �. �; <br /> ,^Distance to nearest: Well -. _ _______________ Foundation -------------- Property Line _______._________-_. <br /> ----- ------ ----- - me � ,e- _ ,--....._ - <br /> SEEPAGE PIT [ ) Depth _ Diameter ______________ _ umber --__-_._____________________ Rock'gilled Yes ❑ No i['" <br /> Water Table Depth <br /> �}_ Rock Size <br /> Distance toynearest:,Well -_ _ _T_-.____ Foundation ____________________ Prop. Line ---------------------- <br /> 4 $$ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------1 <br /> SepticTank (Specify Requieem rits) ----------------------------------------------------------------------------------------------------------------1---------------------------- <br /> - - ----- - - -- -------------- ---------------- <br /> ------------------------------ - - ------ --W1 -------------------------- <br /> I .(Draw existing and required addition on reverse side) yam_ gy. <br /> 1 hereby certify that 1 have rep)ared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, State-ILaws, )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 /> = a <br /> Signed --- ------- -------- F ------------------------------------------------------ Owner <br /> 1 <br /> (Ivine f other <br /> than aI <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED 01-'- _ - = -- = -- ---------------------------------------------------------- DATE ----- ------------------ t <br /> BUILDING PERMIT ISSUED ---!__-" `-------------------------------------------------------------- -- -----=--------------DATE ------------------------------------- <br /> ADDITIONAL COMMENTS ---i 1 --------------------------------------------------- t <br /> ----------------------------------------------- ---- <br /> ------------------------ -------------------------------- -------------- ---------- ----------------- --------------- <br /> ------------- <br /> ----------------------------------------------- - --------- <br /> ------------------------------------------------------------------------------------------------------------------------------------------ <br /> ---- -------------------------------------------------------------------------------- --------------- <br /> -------------- --- <br /> YFinal Inspection b <br /> Date _... ----------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />