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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> - Permit No. - fjS3 <br /> (Complete in Triplicate) <br /> ----------1--------- ----------------------------------- Date issued <br /> --------------------------------------- This Permit Expires 1 Year From 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 made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION -------J 2---------�`4-- ------------------------ ---------------CENSUS TRACT <br /> G � -/j <br /> -- <br /> -------- <br /> wner's Name --- 9AQ)9---- _A// r-(711 -------------------------------- _----=- '- -- --------Phone ------------------------------ <br /> Address ' a ---------- -- <br /> City <br /> ics Phone _OAContractor s Name ----- -Z -A. - L � <br /> Installation will serve:_--- " Residence IV Apartment House-• Commercial Trailer Court ;❑ <br /> Motel ❑ Other ------- -- --------------- <br /> ,�. <br /> Number of living units-.------ Numberwof,bedroo ss ------------Garbc�ge Grinder ------------ Lot Size 61e--� ...... - ------•• <br /> Water Supply: Public System and ame --------_ -------------- -- - <br /> -- Private ❑ <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt[-].. Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam <br /> i ' <br /> Hardpan 0, AdobeT Fill Material ------------ If yes, type ---------- ----------------- <br /> (Plot plan, showing size of lot, 1 ation,of'system in relation !to wells` buildings,-etc_ must be placed on reverse side.) <br /> I NEW INSTALLATION` septic-tank or seepage pit<permit#ec4�'if.publick`sewer-is available within 200 feet,) <br /> PACKAGE TREATMENT [ SEPTIC TANK [ ] n Size--6'r��--f-X-5 "-----. ;Liquid Depth _--- - -__--_..---- <br /> i --Typel`/rt;- `---Material��--------- No. Compartments <br /> i f Capacity�� <br /> Distance to nearest: Well ------------------------------------Foundati n ------------ ---------- Prop. Line ------------.:__----.- <br /> LEACHING LINE [ ] No. of Lines ---.sem--------------- Length of each line--,Ta----------------- Tota! Length ��-�--------•---- --I <br /> � a YP _// p 4 a s ----- -- ---------------------------------- <br /> ------ <br /> -- ---------------------- <br /> �D Box -_-. ____-_ Type Filter Material �f X>�lo�.De th Filter Material ��---__- -- ' <br /> Founddtian 1 Property"Line ---�1 <br /> ��stance.+to nearest: Wel! --------------- -ti�--- ---------- <br /> SEEPAGE PIT [ .] Depth -- ,�-_---- Diameter 33----- Number------ -�'.----- �- Rock Filled Yes � No I❑ <br /> Water Table Depth ------Rock Size --.--------"---_- ' <br /> A. <br /> -•-----_-• i.aryl <br /> Distance to nearest: �-------------------------------------Foundation ------- --------•-- Prop. Line --- `----.-------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date --_---..---_-__------__-.--------} <br /> k Septic Tank (Specify.Requirements)"`---.� _.--------------- ----- �_ <br /> ------------------------------ <br /> , ?­iE--A <br /> Disposal Field {Specify Requirements) ------------- ----------------------------- ',°.-t. ; <br /> I r • <br /> -------------------------- ---------------------- <br /> -- --- -------------------- <br /> -- -------1------ ---- --- ------------- --"------------------ -----------------------------=----------------- ------------------------------- -------------------------------------------- <br /> (Draw existing and required addition on reverse side) * <br /> I hereby certify that I have prepared this applicatio and that`the wark will^be done in accorddnce 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%O t\ N� <br /> [ "1 certify that in'the perfor'mance of the work for which this permit is issued, I shall not employ any person in such manner <br /> as to become subject to W kma Comp sati.on laws of California." i <br /> ; <br /> Signed --=- ------. ,� $� -- ~� Owner <br /> BY ----------------------- -------- ------------------\ Title -------------------------------- ---"-- <br /> (If'o#her than',owner)_ <br /> DEPART ENT USE ONLY <br /> --ACCEPTED-gy = __�E L✓ , 5 �'-------=---------- DAT'---- :-= --- -�= ---•--------- <br /> APPLICATION <br /> BUILDING PERMIT\ISSUED ���, DATE ------ }------------------------- <br /> _ ----- Q(,J <br /> ADDITIONAL COMMENTS <br /> _.---�T � _ .� - ___ - ------------------------------------------------------------------ <br /> i - ----- ---- ----- = _ <br /> f ------------------------------------------------------- <br /> --------------------------------------- -- --- -------------- ------------------------------------ <br /> j = - ------------------------ ---------- Date ' <br /> % <br /> Final Inspection by: _- -- <br /> 54 <br /> SAN JOAQUIN LOCAL HEALTH•DISTRICT <br /> r <br /> E. H. 9 1-'68 Rev. 5M. <br /> �,. a <br />