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r FOR OFFICE USE: " APPLICATION FOR SANITATION PERMIT <br /> it <br /> Permit No. l� <br /> I� (Complete In Triplicate} _. .�..� <br /> This Permit Expires t Year From Date Issued flats Issued ...5.. � �5 <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 Regulatlons: <br /> 11 , <br /> � <br /> - lad <br /> JOB ADDRESS/LOCATi !II-�._..-.2-.._..._.__.v....'.�...../.._. .....................................CENSUS TRACT .................... <br /> ...... ..........Phone ...................,............ <br /> All <br /> Owner's Name ...... . . . ----- 1 <br /> Address ......... ....... City .... <br /> .............................. <br /> Contractor's Name .....------ ttb: . ....--- <br /> ...License # `. ,!j' . Phone .............................. <br /> �-0Ycd:4..f . <br /> Installation will serve: ii Residence fApartment.House 0 Commercial❑'frailer Court <br /> Motel ❑Other ............ <br /> ............................... <br /> Number of living units ..... Number of bedrooms ...._�_�_...Garbage Grinder ............ Lot Size ............................................ i <br /> i <br /> Water Supply: Public System and name � Private <br /> Character of soil to a depth'of 3 feet: Sand❑ ilt 0 Clay ❑ Peat❑ Sandy Loam 0 Clay Loam ❑ <br /> 4 Hardpan Adobe'❑ Fill Material ............ 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: lNo septic tank or seepage .pit ,permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT I ]�� SEPTIC TANK-f I Size................................................ Liquid Depth .....................,...... <br /> Capacity -------------------- Type ---------,-- ....... Material.......-----------.--- No. Compartments ...-.-................ <br /> Distance..to nearest: Well -------------------............. Foundation ...................... Prop. Line ... .................. <br /> LEACHING LINE [ ) No. of Lines .....................:.. Length of each line...................I........ Total Length ............................ 0 <br /> ©'ll Box ............. Type Filter Material ....................Depth Filter Material ... ............_.........._...:_._ ........ <br /> Distance to nearest: Well .....- ----------------- Foundation ........................ .Property Line ........................� <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter _.__... -------- Number ............................ Rock Filled Yes ❑ No i❑ <br /> Water Table Depth -•---- ---•;:- ............ .•--.Rock Size ................ ............... <br /> i; I <br /> Distance to nearest: Well -------.................................Foundation ..................._ Prop. Line ......................`. <br /> iZ V <br /> EPAIR/ADDITION(�r��. Sanitation Permit=# _........---•.........................••---- Date ----•------:..-----.----••-••-•-•-I <br /> SepticTank (Specify Requirements) ----------------•--------•---- -----------------------..............•-•------------------.......--....�............---••---•---.._.........- <br /> Disposal Field (Specify Requirements) --- C,� ?! z i.. ;�! ""`'......................:..... a, <br /> ► "'r`r' <br /> v � - <br /> . - ---- •------------------------•--..........-- <br /> II ...............---........................................ <br /> ri: (Draw existing and required addition on reverse sidel <br /> M ; � <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 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 -------------=--•---------------II---- -- •--- --- Owner <br /> By ---- ---------------- •----------- -- fr �r + 1"�' ,.. ..... Titae d 's'. <br /> (if other than; owner) <br /> I' FOR DEPARTMENT USE ONLY N 01 <br /> ACCEPTED BY _-.- __ DATE.,�,.. !: 7 <br /> ' -------------- <br /> APPLICATION <br /> BUILDINGPERMIT ISSUED!------- ----------------------------------- --------------------------•----•-•------------•..- ----------------.---DATE ....-•----------------.....__..._.-_.-._._. <br /> ADDITIONALCOMMENTS 1'- ---------------------------------.-.•-------------------------------------- ................------.... ----------------- ................ <br /> ---------------------------- ----------- -------------------------------- ------------------------------------------------------------ ----- ..._......------------------...._.-------------- <br /> f ........................ ------------------------------ -----------------•--------------- ---------------------------- ------------------------ ------------------------------------- -- ....._...... <br /> �, ---------- -- . <br /> mss: <br /> Final Inspection b ...............................--------- <br /> ---...._Date --- -• ---. ._-�`' <br /> EH 13 2h 1-•68 Rev.:` 5M SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M <br /> l <br />