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FGR OFFICE USE 3 APPLICATION FOR SANITATION PERMIT <br /> = ':: -_ Permit No <br /> (Complete in Triplicate) <br /> ------------I This Permit Expires f Year From Date Issued 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 o. 5 ? existing Rules and Regulations: <br /> _ � � CENSUS AC <br /> to let <br /> JOB ADDRESS/LOCATION __. -- f --- <br /> i 4 � ` <br /> Owner's Name ---- J ! 1' �--- ,A�, --- ',t+1 - `" ,µ Phane <br /> r - ----------- <br /> Address `\ .. A 3;f.,.. -------------- itY `f � ------------------------- ---- ------- <br /> �- 4 <br /> 10 <br /> Contractor's Name :T�f <br /> �� 3 <br /> Installation will serve: ,^ esidence`[�Apartment House ❑ Commercial ❑Trailer Court :❑ <br /> Motel ❑ Other.,------ ------------------- -------------- <br /> Number of living units:__:_____._ Number of-bedrooms i--:_:Garbage„Grincier ------ ----- Lot------ - Size ___._______f` -�______________________ <br /> :� • . <br /> Water Supply: Public System and name --- fy -r; ---Private <br /> _ <br /> Character of soil to�a depth of 3 feet: Sand Silt❑' ,,.Clay .❑., Peat,❑ Sandy Loam,❑.—Clay Loam ;❑ <br /> a <br /> �. <br /> Hardpan El '❑._Fill-Material ----- If yes,type ________ ____________ <br /> (Plot plan, showing size°'ofilot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> It I <br /> NEW INSTALLATIJ_hON: r(No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ I SEPTIC TANK'[ ] Siz>e----------------------------- -----------_------ Liquid Depth --------- ------------ <br /> 0 Type -P” --- Material--6x Na. Compartments ---�----- --•_- J <br /> --Foundation -----/d_____------ Pro Line ----_______-•_-. -0 <br /> Distance to nearest: Well __ _______________ p. ► <br /> LEACHING LINE [ ! <br /> No,'of Lines __ Length', of each line----------------------- ------ Total Length ---------------------------- <br /> D' <br /> _________________D' Box __ _ Type Filter Material -----i'__/-----,Depth Filter Material --------III------------------___________-_-� <br /> Distance to nearest: Well ---------'-------_1------ Foundation ------------------------ Property; Line, ______r_________------ , <br /> SEEPAGE PIT [ ] Depth - Diameter 11o______ Number -- ------- led Yes No .❑ <br /> .... ._ Water Table Depth ------------------------------------------------Rock Size --------�------------------- r0 <br /> �. Fo <br /> :., Distance to nearest: Well ------------- ---- ------ undation ------ _ ........ Prop. Line ------ <br /> REPAIR/ADDITION <br /> ----- --....._.---- '� <br /> REPAIR/ADD1TION(Prev. Sanitation Permit# -------_-._________F--------:---------------- Date __________________________________} l <br /> Septic Tank;(Specify Requirements[ -------- -----------------•--------------------- ---------------------------------- - <br /> Disposal Field 41 u <br /> ' (Specify Requiremenfis) ----------- <br /> -------------- <br /> , <br /> ------------------------------------------------ <br /> _____________________.______________.______.__ - ----- <br /> --- <br /> --- <br /> --- <br /> ____--- <br /> _____''--- <br /> ------ <br /> ---- <br /> '-- - - -- - -- - - - <br /> ____- - - -------- <br /> ________ - - _ _------A---------- ------- <br /> { {Draw existing and required addition on reverse side} <br /> hereby certify that I have prepared this application and that the work will be done in accordance i0h-San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health�District. Hotne.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 --=•------------------------�---j-�------------------------------------------------------ <br /> =----------- Owner . <br /> By - - /I/�-- ------- �` Title ==----- --------------- ------ ------------------= t <br /> f <br /> (If other than owner) <br /> FOR .DEPARTMENT USE eONLY <br /> APPLICATION ACCEPTED BY -------------- - : !` ='yet __ -------------;'----------------------------------- DATE -----= ---------------- ------------------- <br /> BUILDING <br /> ---:--- -BUILDING PERMIT ISSUED ------ --- ---------------------------- ------- -- --------------DATE .-------------------------------- <br /> ADDITIONALCOMMENTS ---------------------------------- -------------------------------------------------------- ----------------------- -------------•-----------•---=---------- <br /> --- ---------------- ------------------------------------------------------------------------'-•°_------------------- --=-----------------------------------•---------------------------------- ----------- <br /> ------------------------------------------------------------------------- ----------------------------------------------------------------•-•------------------------------------------------------------- <br /> ------- ----------------- ---------------------- -- -- ----- ----------------------------------------- ---------------- ------------------ - = ---=•----- <br /> Final Inspection by: `� <br /> ___ WSJ 3 r +,� <br /> ----------------- -` :: Date - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> • C� <br /> E. H. 9 1-'68 Rev. 5M _ ':� <br />