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FOR OFFICE aJSE., APPLICATION FOR SANITATION PERMIT C, <br /> ------ ----- - - ------------------ ------------ - Complete in Triplicate) Permit neo.'_9_!'. 3..Q-.. <br /> ---------=----------------------------------------------- <br /> ®� �I teql\ Date Issued _.-1-_1 y__ 7 <br /> _ <br /> ---------------------_---------------_------------------- This Permit Expires 1 Y r 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.-k- '__/_-----ca2_E------------;5A.?V____LTA AG4CIE_---CENSUS TRACT --------------.-------____ <br /> Owner's Name ---------------------------------e-' -----------------------­----- ------------------- -------Phone ------- ............................ <br /> Address ------------- ----------------------- = City ---------------------------------------------------------------------------- <br /> Contractor's Name ---JV_Al----- Z_I 5---------------------------------------- --------License # ------------------------ Phone / <br /> Installation will serve: Residence ❑ Apartment House❑ Commercial ❑Trailer Court i❑ <br /> Motel ❑Other -------------------------------------------- <br /> Number of living units:------------ Number of bedrooms ----I_......Garbage Grinder ------------ Lot Size __----- <br /> Water Supply: Public System and name -----------------------------------------------•---------------------------------------------------•-----------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam Z�--' <br /> Hardpan ❑ Adobe ❑ Fill Material ------------ If yes,type ____________________________ A <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 publics wer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK:[ ] Size--- --------------------------------- Liquid Depth <br /> -- <br /> __-___-_-__-_____ <br /> CaPacity _.,__ Type B&7�-O aterial---------------------- <br /> No. Compartments ...oz+............ <br /> Distance to nearest: Well ________________________________--Foundation ---------------------- Prop. Line ...................... <br /> IN <br /> LEACHING LINE No. of Lines _______/--------------[ ] � Length of each line---------_------------------ Total Length -----910__.............. <br /> 'D' Box ---/__------ Type Filter Material --------------------Depth Filter Material -------------------------------------------- -A <br /> Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line ..-_.__.-____ <br /> SEEPAGE PIT [ ] Depth ____ --------------- Diameter ---------------- Number -.----.--------------------- Rock Filled Yes ❑ No 0 <br /> Water Table Depth ------------------------------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well ________________________________________Foundation -------------------- Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ------------------------_---------) <br /> Septic Tank (Specify Requirements) ------------------------------------- -----•---------•----«.-------------•---••-------- <br /> Disposal Field (Specify Requirements) ----__._... <br /> -------------------------------------------------------- ----- ------------ - - - - ------------------------------------------------------------------------- ----------------- <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that 1 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, I shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed - ----- ------ ------------ <br /> ------------------- ----- ------------- Owne <br /> � r <br /> e <br /> By -- ' T ---------------- -------------- <br /> Title <br /> �`� <br /> (If other than ow e� <br /> FOR DEPARTMENT N <br /> APPLICATION ACCEPTED BY------------------ - ---------- DATE --- - <br /> BUILDING PERMIT ISSUED __________________________________ -' <br /> -------- -------- -------------------- ------ - ----------------------DATE ------------------------------------------- <br /> ADDITIONALCOMMENTS ----------------------------------------- ------------------ ----=---------------------- ----------------- ----- --------------------------- <br /> -------------------------•-------------------------------------------------- ----•----------------------------------- --------------------i------------•-----------------------•---- <br /> -------------------------------------------------------------------------------------------------------------------------- - - - - - <br /> --- --- - -- ------ <br /> Final Inspection b ---------- ------ -- <br /> Py: ----------------------------------------------------------------- ----- - -------- ---Date -- <br /> SAN JOAQUIN LOCAL HEAL DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />