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FOR OFFIC E.JSE: s <br /> APPLICATION FOR SANITATION PERMIT �� l Ga <br /> 3._ °--------------- <br /> - --- --------- Perm No: r I <br /> „ i (Complete in Triplicate) <br /> ------------------------------------- <br /> 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 F <br /> described. This application is made in compliance with County Ordinance No. 544 and existing Rules and Regulations. <br /> 1.JOB ADDRESS/LOCATION / t <br /> �J ■yGC� CENSUS TRACT _ ._ <br /> -_ - ___. l� <br /> Owner's Name -------------- ---------- ---- ---- - <br /> Mo.ne --7.6-�- -- ��� <br /> ---- <br /> Address - Y� _QA f '�/ Ci ---------- -------------- -----------------------•-------------•--- <br /> f � -- <br /> Contractor's Name #. � � <br /> --------License# ftb1 Phone <br /> Installation will serve: Residence Apartment House,0 Comme cr 6ll'oTrailer Coin ❑ <br /> ,c� I <br /> Motel, �+ <br /> . ,.Other ------------------ -------------------------� <br /> I <br /> Number of li ing units:-__�______ Number ofbedrooms ___3____Garbage-Grander Lot Size _______________________ __.__________-.--. <br /> Water Supply: Public System and name ------------------------------------------------------------ - Private <br /> `, <br /> Characte ;of soil to a depth of 3 feet: Sand'M Silt❑ Clay ❑ Peat ❑ Sandy Loam -❑ Clay Loam ❑ j <br /> Hardpan ❑ Adobe Fill Material _----------- If yes,type __________________________ <br /> (Plot plan, showing size of lot, location ofF system i relation toawellS, u Idings, etc. must be placed on reverse side.) V <br /> x <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT .[,A SEPTIC TANSize---, ------------------------------------ --- Liquid Depth ---_-----------------.----- <br /> : fi i'�T At <br /> Ca ocit ------------vNt� -- ----------------- G] <br /> No. Compartments ------------ <br /> Dis#ance�te nearest: Well ------------------Foundation -------------#---- --- Prop. Line ---------- -•--------- <br /> NE [ I No. of Lines ___-_-----_____----__ Length of eachline____________________________ Total Length ._____-___..____....___._ <br /> ------- <br /> LEACHING LI 'DBoxType Filter Material ___________________Depth Filter Material ______-________________________------___-.- <br /> Distance to nearest: Well _1---'�"--�'_l'oundation—.________ - •Property Line ________ <br /> SEEPAGE PIT De'th --- Rock Filled Yes No <br /> [ 1 P --------- -- Diameter Number ❑ <br /> i <br /> � Water Table Depth -�-------------------------------------------Rack Size ------------- - -------------- <br /> +Distance to nearest. Well ___________________________-_._------_Foundation --------- ---------- Prop. Line ...._____-.__-----._- <br /> *%f f <br /> REPAIR/ADDITION(Prev. Sanitation Perm it# ------------------------------------------- Date -------------------------------- <br /> i --} <br /> � � f <br /> Septic Tank [Specify Requrements)�------------------------- --- -- - --------------------------�--- -------------- <br /> - -- ------ - --- - ------------- <br /> Disposal Field (Specify {Requirements) ---------- -------6_ ,------- <br /> -- -- -------------------- _: <br /> F` _________5___________________ _ __ ___, _____ __`_____ ______---- __.___.____. <br /> ------------------------------------------- ---------------------------------------—----------- -------------- -------------------------------------------------------- <br /> I(Draw existingand - <br /> required addition on reverse side) <br /> I hereby certify that I hav prepared this application and that the work will be done in accordance with San Joaquin + <br /> County Ordinances, Slate 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, I shall not employ any prson in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed ------------"than <br /> ---- ------- Owner <br /> ---------- <br /> BY ------ ------ ----- -- <br /> Title . ---- -- - ---------------- <br /> ( ed <br /> 12 FOR .DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -- - - -------- -------- t= - ') --- DATE ........ --- ------ <br /> BUILDING PERMIT ISSUED ---------- t--------------------------------- ---- '`--- .. -------#�-------------DATE ------ --- --------- <br /> ADDITIONALCOMMENTS ------ ----- °------------------------------------------------------------------------------------------------------ --------------------------- ...... <br /> ----------------- ------------- -------------------------------------------------------------------------------------------------------------------------------..-•------------------------------ ------ <br /> ----------------- ----------- ------------------------------------------------------------------------------------- ---------------------------------- <br /> ------------ <br /> ---- 4- ----�_ -------- <br /> Final Inspection by --------------------------------------------------------- ----- ------------Date �� 7- (------ <br /> SA <br /> -------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br /> J <br />