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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT 'y. <br /> ......__ ---------- Permit Nax.,&1`10_. <br /> (Comnplefe in Tripficafe) <br /> __... _ .. _.._. __ ...R. .. , .�.-.__....__ . ... ._....___ ..._�. / <br /> This.Permit Expires I Year From Date Issued Date Isaued!�:� <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 modsincompliance with County Ordinance.QN 5, 9 and exists Rul s and Regufatioru:� <br /> JOB ADDRESS/LOCATI '..t <br /> ... ... .................... .....:_........................CE VS TACT .......,................... <br /> Owner's Name ....... 4 ►. ...................... ..---...... ........:. ...................... ....,..... ...Phogie <br /> Address . - ..... - ....---- City <br /> . . .. .__....- <br /> .. . ....... <br /> Contractor's Name _.. ..�. ._.Gt/�?%-------------•- �'' — � Phone .. <br /> . ...-•........ ....... ...........:License � .................. .....�..1�.��. <br /> Installation will serve: Residencelid Apartment House C) Commercial#]Troller Court <br /> Motel ❑Other ...--- ..... . ........ <br /> Number of living units:........ Number of bedrooms IF I n d Br ..,....:.... Lot Size . .....1,---------- <br /> Water Supply: Public System and name - e • --•................• ---......----- .........._........... :-.......:.....:................. rivate. , <br /> Character of soil to a depth of 3 feet: Sand❑ Silt I] Clay ❑ Peat❑ Sandy Loom.0 Clay Loam <br /> Hardpan 0 AdobejX—FillMaterial .......-.... 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 within 240 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK f I Size—............. .............................. Liquid Depth .......................... <br /> Capacity <br /> ---•---•_......_..__ Type -------------•...... Material............__.-•-:.;.N ,,,, <br /> o. Compartments ----................ <br /> Distance to nearest: Well ...... ............................Foundation ....................... Prop. Line -- <br /> LEACHING LINE [ j No. of Lines ........................ Length of each line................__._........ Total Length ` <br /> 'D' Box .... .°..... Type Filter Material . .Depth Filter Material ........... .. <br /> : Distance to nearest; Well ........................ Foundation ................... Property line ........................ <br /> SEEPAGE PIT DepthDiameter Number .................. ......... Rock Filled Yes ❑ No 0 <br /> 1 Toter Table Depth ---- ................. .......Rock Size <br /> Distance to nearest: Well ........................................Foundation. .......:............ Prop. Line ...........:.......... <br /> It1"PAIiR/A6DITION(Prey. Sanitation Permit ---..-------------- ----..'._.._....... Date ...............................-__) <br /> Septic Tank {Specify Requirements). 'ma c . --•----•-- ` -------•-------•-... .........:- •----- ..........................• <br /> Disposal Field (Specify Requirements) ---- - ------ ---- --- - F ... <br /> t� .. <br /> -•-------.... .�.�.......................... <br /> G. <br /> r <br /> (Draw existing and r quire addition on reverse side) <br /> 1 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 #icon- <br /> sed agents signature certifies the following: ` <br /> "I certify that in the p rmance of the work fpr which t ermit is issued, I shall not employ any person in such manner: <br /> as to beco ub ect t rkrn jn's Compens or laws oT Iifornia." <br /> Signed ----- L------q ` r __ -_. IZ ; <br /> By -------• ----------------- -------••-- ------------------ Title <br /> (If other than owner) <br /> -Ag7 <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY _..... . ---------- ------------------- ------------ DATE <br /> BUILDING'PERMITASSUED-_.:`_"...__.---•---- -•.._� : :: <br /> DATE . <br /> ADDITIONAL COMMENTS ---------------------------•....._...._..-- ....._. ....._-.....- _.. .. <br /> ---------------- ------------------------ --------- <br /> -----------------------•------- <br /> Final Inspection by: : _ "1 , -11 •.... _..__...._..--- --------------------- <br /> ---------------------Date ... <br /> EH 13 .2h 1-68 Rev. 5M <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT , <br /> 8/7h 3M <br />