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J ,.vFOR OFFICE USE: <br /> APPLICATION FSR SANITATION PERMIT <br /> -- ----------------------- ----------- ---------fes Permit Na. ..�------_� <br /> 3;, ( � I i (Complete in Triplicate) - <br /> -------------------------------- - - --------- .�_/ _�1 <br /> -- . _-t 4,w Date.Issued - i <br /> ------------------------------------------_.t...---.---- ' This Permit Expires 1 Year From Date Issued%- <br /> t <br /> Application is hereby made to the Joaquin Local Health District for a permit to construct and install the work herein <br /> described. This application is made ' in compliance with County <br /> Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCAT ON . -- ------------------ /; ------------------ --------------------CENSUS TRACT <br /> r± -s - :. 1. <br /> Owner's Name L <br /> -��� ------- �'Gr�F-- - ------------ -------- --- ---------"----"--------- _ -'"------------------ ---- ---------------- <br /> --------------------------------- <br /> Address <br /> ----------------- ----------- <br /> Address ..__._ <br /> City - ----- _ <br /> ?# <br /> Contractor's Name ____. ��'__�- _ ----- -- - -- _--_-- � _.. !-- License # <br /> Installation will serve: Res idenceXApartment House❑ Commercial .❑Trailer Court 'E] F <br /> Motel Other <br /> Number of living units:--- ...----- Number of bedrooms ..-f-----Garbage'Grinder -- Lot Size _09�1_l'C--- <br /> w�P -____ <br /> Water Supply: Public System and name ._ ------I ----------------------------------------------private ❑ <br /> Character of soil to a dept of 3 feet: anE] 0 Clay. E] ❑ <br /> . Sand-E] Silt ClPeat Sandy Loam Clay Loam❑ <br /> 4-i i <br /> ' »"•• H"ardpan❑' `Adobe'�iII Maal ------_-_ If yes, type ---------------------------- <br /> r <br /> (Piot plan, showing size of lot, location of system in relation t w Is: 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 /> r <br /> PACKAGE TREATMENT ( .] SEPTIC TANK'[ ] Size--.-_------------------------------------------- Liquid Depth ----------------------- <br /> Capacity <br /> -------------------,-•--.5 <br /> Ca acit hll' <br /> P Y ------- - ------- Type ------------- atm ial------------- -------- No. Compartments --- ------------------ <br /> Distance to nearest: Well --------------------------- -:---Foundation ---------------------- Prop. Line ---------------------- <br /> ' <br /> -----.-------------. V�4 <br /> LEACHING LINE es ----------------.-------- Length of,each#line--- -------------_.------ Total, Length .-----------..-..-..-------- <br /> [ ] NDo.B of Lines � t <br /> ------ Type,Filter Material --------------------Depth Filter Material --------------------- ---------------------- <br /> Distance to inearest: Well - .-..-_____.......- Foundation ------------------------ Property Line 1---.._.....__..------- <br /> SEEPAGE PIT [ ] Depth ----- - ------------ Diameter .-...._.---_-___ Number ------..-.___________------ Rock Filled Yes ❑ No i❑ <br /> Water Table Depth ------------------------------------------ Rock Size -------------------------------- <br /> ,l <br /> Distance tolnearest: Well _ .--.---------------------Foundation -..-.-__ ---------- Prop. Line ----------------- <br /> REPAIR/ADDITION(Prey. Sanitation(Permit# --------------------------------------------- Date ----------- -------.-------------_) <br /> Septic Tank (Specify Requirements) --------------- ----- ---- - ---------------- ---- -------- -------------------------------- <br /> Disposal Field (Specify Requirements); ------6�------- ._ - `'6 s <br /> ------------ <br /> -- -` ------- I <br /> J <br /> (Dravt existing and required addition on reverse side) I' <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 cdkfies the followWg: i <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 4o Workman's;Corn en tion laws of California." i <br /> --- - 'W <br /> Signed -------------------------- -- Owner <br /> BY Title .. <br /> .. <br /> (if oth an owner) :I <br /> t FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY --- $ - - ----------------------------- ------ DATE ---------------- <br /> BUILDING PERMIT ISSUED -DATE ------------------------------------------- <br /> ADDITIONAL COMMENTS ----------------- <br /> -- ------------ <br /> - <br /> e <br /> --------- ----- ------------- - - ----- ---- - ---------------------------------------------------------------------- ------- ---------- <br /> --------- <br /> -------------- ., -- f f ....................... <br /> � <br /> Final Inspection by ------- <br /> : -.. <br /> ----------Date ✓�._ 4 .. ... - <br /> _ SAN JOAQUIN LOCAL' HEALTH DISTRICT- <br /> 9 1-'68 Rev. 5M <br />