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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> , '� s -_ Permit No-- ---- �fJ- =--�� <br /> -'-------- 3 3 ° <br /> [Complete in Triplicate <br /> ----------- ------- - - � Date Issued <br /> This Permit Expires 1 Year From Date issued <br /> ----------------------------- <br /> ---------- - t <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..5A9 and existing Rules and Regulations: <br /> •- r__. ._� _ u,_ ° CENSUS-TRACT `n-- <br /> . ° <br /> JOB-ADDRESS/LOCATiON':�_ �--n - <br /> f _ . - ---.,----7-Phone- ------------------------------- <br /> !C -_- <br /> Owner s Name __ ' �Tl- l r - ----------------- k:. <br /> -.,_ <br /> --- - -- ----- - -_City <br /> Address ---' -- .. _ .. . - ---- - - - =-:_------ -=-=----=----==-----------=----=='�----------- <br /> ,.rte _ =------------ <br /> �J C�,, J se:.#/,a?. _ Phone S� <br /> . � - _ 1 f� Licen -- <br /> Contr_ �.Pr <br /> actor s-Name _..._ �` ---`�---- <br /> Installation will server Residen'ce,❑ ApartmentMouse❑ Comrnerciaf XTraileraCourt ❑ <br /> -- - <br /> ' Motel ❑ Other f <br /> .:r t <br /> Garbage,Grinder ':------ ''Lot Size -------------------------------------------- <br /> Number of livingunits:-- Number of bedrooms --- ,. t <br /> y " - va <br /> Water Supply: Public,System`•and name -- .�1 -----�- ----+---- - � - - --------------------------------Pry- e ❑- <br /> Character.of soil to a depth of 3 feet: Sand'[] Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Cloy Loam ❑ <br /> YHardpan ❑ Adobe' Fill Material If yes,type ---------------------------- J <br /> ! t� <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 public sewer is available within 200 feet,] '. <br /> PACKAGE TREATMENT [ ] SEPTIC TANK' Size--------------------------- ----------- ----- Liquid Depth ---------------- ---.-- <br /> Capacity � T- <br /> Distance <br /> Material----------------------CaNo. Compartments .-------------•--P Y ----------- - T�pp----- ----to nearest: Well ------------------------------------Foundation _.-------------------- Prop. Line ---------- •---------- <br /> LEACHING LINE ] No. of Lines ---------y�------------ Length of each line---------------------------- Total Length -. ---_._- <br /> De Depth Filter Material --------- <br /> ----- <br /> - -- ------------------------•-- _,.`_... <br /> 'D' Box .---_�,f,TSeilerfMa e I -------------------- P <br /> ----- Foundation ------------- Property Line ------::-•--------;. <br /> Distance to nearest: Well ________________ -------- - <br /> SEEPAGE PIT [ j Depth <br /> ,®iamete� ; Number --------------------- Rock Filled Yes ❑ No , <br /> Rock Size = •- <br /> •- t Water Tableth/__-_s� � -�---'- ----- <br /> -;�. Distance to nearest; Well ------------------- Foundation Prop. Line <br /> - <br /> 'L. .' Date ............. <br /> ------------------ <br /> REPAIRfADDITION(Preva Sanitation Permit�# -------------------------------------------- <br /> Tank (Specify Requirements) -------- - ------------------------ <br /> ------------------- <br /> L <br /> -=------- ---- =�.. <br /> - r <br /> LI ----- � 9--�_0--- 'Trc'A'-' j <br /> Di osal Field {Specify ,Requirements} ► j+ --___ _ _ j i <br /> ' --- <br /> ---------r----- <br /> -------- ---- -- - - - - - ---------ng an :' <br /> {Drawexistid 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 Sri Joaquin Local Health District. Home owner or licen- <br /> sed agents signature certifies the following: r J`4 I <br /> "I certify that in the performance of the work for which this permit iii issued, I shall,not employ any person in such mPnner <br /> as to become subject to Workman's Compensation laws of California." _ 1 I <br /> Signed Owner <br /> ----------------- <br /> ;title _ - _. .Ll ------- --- ---- --------- <br /> BY i <br /> (If t er than ovuner <br /> FOR DEPARTMENT U55 ONLY <br /> DATE - ' ' =-------- - <br /> APPLICATION ACCEPTED BY r � "----------------------------------------------- DATE ------- -------- <br /> BUILDING PERMIT ISSUED -------------- ---------- ----------------------- -- ------------------------ <br /> -- ------------ <br /> , <br /> ADDITIONALCOMMENTS ---------------------------------------------- -------------------------------------------------------------------------- <br /> ------------_ -------------------------------------`------ <br /> t _ --•------- <br /> k __________________________________------------------- <br /> - <br /> _____ _______ ___------------------------------------------------------------___ e__---_______.-----________---__________--_-_______._---____-__-__---_______-.- __._____ <br /> ---------------- <br /> ----------------------------- <br /> --------------------- ------------ -- .Date -- •-- <br /> Fina! Inspection-by. <br /> [ <br /> f a SAN. JOAQUIN LOCAL. HEALTH DISTRICT <br /> tp 9 <br /> E. H. 9 1-'68 Rev. 5M, <br />