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Y x i <br /> FOR OFFICE USE: <br /> ......................... ................ <br /> APPLICATION FOR SANITATION PERMIT � <br /> .......... ...................... ............ <br /> (Complete in-Triplicate}­ Permit No. _76 <br /> ......... .......... 1 This Permit Expires 1 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 No. 544 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION .:.�J.�_.Fy ....: .. _.. .> o .o- : ..............CENSUS TRACT ....... ....... <br /> I <br /> Owner's Name 1 .. T �..... - --- • -------------•----•----- _ -.---..... oneV. <br /> ............................................ <br /> Address ------- ..-�. -... .. <br /> "C ty <br /> Contractor's Name --L-� .-4...... .........:. .......... ._ --.---._.License # � x.3 . Phone ..--••--------- .............. Ji <br /> Installation will serve: Residence [t(Aportment House❑ Commercial {]Trailer Court (3 { <br /> Motel ❑Other ..................................� <br /> .......... <br /> Number of living units-1------- Number of bedrooms......Garbage Grinder ------------ Lot Size ............................................ <br /> Water Supply: Public System and name --------------------------------------------•--...... ---------- -------------------------------- .......Private <br /> Character of soil to a depth of 3;feet:. Sand❑ ilt E] Clay. <br /> ❑ Peat❑ Sandy Loam fl Clay Loam <br /> Hardpan Adobe o Fill Material ............ If yes,type ............................ <br /> jPlot 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 public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ) SEPTIC TANK j Size................................................ Liquid Depth `1 <br /> Capacity Type ... _j <br /> Distance to nearest: Well ....................................Foundation ...................... Prop. Line ............. ...... <br /> LEACHING LINE [ ] �No. of Lines, --------------- Length of each line._'............. _. Total Length ......................... <br /> -'D' Box ......: .... Type Filter Material .._......... .Depth Filter Material <br /> Distance to nearest: Well ........................ Foundation ........................ Property Line ....................... <br /> SEEPAGE PIT [ j Depth -_.._..._...._..___- Diameter ................ Number ............................ Rock Filled Yes ❑ No <br /> Water Table'Depth ......•---••--•.................................Rock Size ---..........4.................. <br /> Distance to nearest: Well --•.......... ..........................Foundation -------._._.-_---- Prop. Line .................. <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ---•---•.................................... Date ---------------.......--•----.•- ) <br /> Septic Tank (Specify Requ'irements)'--•-------.......:..---------............. ....................................................._................................. <br /> r <br /> Disposal Field (Specify Requirements) ..Gt-r � •_---------- <br /> ........... ........ --------------------------------------------------------- •-•-- •----- <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 far 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 /> ` Owner------------------------------------11-7 <br /> BY n . = ......... Title ... <br /> . . :.., <br /> (if other than owner) ' <br /> / eg FOR DEPARTMENT USE ONLY <br /> { - �.U.O .......... DATE .. ....��_ ... .5 <br /> APPLICATION ACCEPTED BY ... .. .....: .. 't•-------.._:_...................._._..------=•-----------•...... ..._.._._... <br /> BUILDING PERMIT ISSUED ........................................'...... ..... <br /> ........ <br /> ...:...... :...................._.••-...•••••.DATE ------•---.......... ...................... <br /> ----------------- <br /> ADDITIONAL COMMENTS ........................•-•----.....--------• - <br /> ........................................................ . ...... -•-•---- ------------------------------------------------------------ .............. ----- -.-- <br /> Final Inspection by: ...rr�- `�_. f.a...... ...- - , ............................................••----....Date ` .-�1 f.` -..... t <br /> ��/ ��-i <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> - <br /> E. H. 13 24 1.'68 Rev. 5M _ ,_...•..a .. -„.. _. .. . -t _ �� t� <br />