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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> ...........................•• ............:...... J Permit No. .- ._ .............. <br /> (Complete in Triplicate) <br /> ......................................_,..... <br /> ....••.........:.:............................:.:.:`:..... '� This Permit Expires 1 Year from Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install they work herein r. <br /> described. This application is made in compliance with County Ordinance No. 5.49 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION,.................. ..Ma-y-bCE%US TRACT .................. <br /> Owner's NameB ??k of: Stockton Phone <br /> ....._.-....... <br /> n_..•--------------------•-•-....----...............,.--.............. ..........----..... .--•••....._.................;.. <br /> Address P.0.'� Bax 1110 - <br /> __..._._---- -.-— - :......City ............. <br /> Contractor's Name Qom............_.......-F--- license # -.:27-I., 3.9..... Phone 465:n26.1.6......... <br /> Installation will serve: Residence{]Apartment House 0 Commercial❑Trailer Court ❑ <br /> ' Motel ❑Other............••-- <br /> i'l-....� Number of bedrooms Garbo- a Grind <br /> Number of living uni ......... g eryea...... lot Size .. .cx ege,:.......................... <br /> Water Supply: Publc System and name ..-•.............•----•-........:.__ .:.:.... :... ....:.............. ..._....... ...........Private <br /> Character of soil to a depth'of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat.(D -Sandy Loam 0 Clay loam ❑ <br /> - t <br /> Hardpan 0 Adobe o Fill Material ...xia..:if yes,type{.............. .......:.... <br /> (Plot plan, showing size of lot,`location of system In relation 'to wells, buildings, etc. must be placed on reverse sl do.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK ] <br /> Size '................................................ Liquid Depth <br /> CapacityType .... Material------ .............. No. 'Com artments -.� <br /> Distance to nearest: Well ................... ._....Foundation :...............i...-_ Prop!Line -_----_---------_ <br /> LEACHING LINE [ } No. of Lines ..................I------ L n t of each line.--F'------------_------:.:•-Total Length ._._..___.........._-•�.:-� <br /> �I i J <br /> 'D': Box Type Filtel• Material ....---Depth .Filter Material <br /> Distance'to nearest.-Well .................4...... foundation ..........._.._. ....... Property Line ....................... <br /> SEEPAGE PIT [ ] Depth ------------------ Diameter ................ Number .........-----._...._.------ Rock Filled Yes ❑ No ❑� <br /> Water Fable Depth .............................Rock Size <br /> } <br /> Distance to nearest: Well ........................................Foundation ----.............._. Prop. ?Line -------.._.._.__..._-- <br /> . � r <br /> REPAIR/ADDITION(Prev. Sanitation Permit# _ Date ................... ! r r <br /> fy Requirements)Septic Tank (S eci Re I . <br /> p p ents) -.•.......................add__�.Qp-'----I.e.a�.h...lin:e_._ <br /> Disposal Field (Specify 'Requirements) --------------------------------------------•-•----•-------------------•----• ------------±------••----•-•--------------- . <br /> ----•-----------•--...... . <br /> ------------------••--- • -- ' <br /> --------- ----------------------------------- <br /> ------------...........--.--.--------------------------------------------------- ............................ <br /> (Draw existing and required addition on reverse side) ] <br /> I hereby certify that I havee prepared this application and that the work will be done In accordance twith San JoaquinT <br /> ► County Ordinances, State laws, and Rules and Regulations of the San Joaquin Local Heal&Distdct. Noine owner or licew <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 /> --- ------------------ ------------ ---••-•----------------------------.. ---------------- Owner <br /> l <br /> By -------....J-ue -;r t -t 2-t-e-------------• ---•---------- ---------- Title --------Con- r-acor.......................•--------- <br /> (If other than owne <br /> FOR DEPARTMENT SE 9 NET <br /> i <br /> e <br /> APPLICATION ACCEPTED BY ---------------------------- �. DATE '..-T.,. <br /> BUILDING PERMIT ISSUED ---------..'--• •-•-•------------------------- --- - <br /> ------ -•-....--- -•--- •- <br /> -----------._DATE ---•----........_.._..._........_..-• ---' <br /> ADDITIONAL COMMENTS ----- i--------- -----••---------------_-- - _..... = <br /> ---------------- " ------'-------..._. <br /> ...................................-:.... ------- -------------------------.-------- ------.--------.------ ----------•- ------ -' ------------------..........--•-------------•--•------ <br /> •-----.....:,_.._.....................-•--•---,- --------......... --•---- �� -- '-_... <br /> final Ins ection b Date ---. <br /> p y ........ :.... ::._:- .:;;..,. _......... --- . ._"._�._.-- ••-------------- <br /> EH 13 2a 1-68 Rev•i5 f SAN JOAQUIN LOCAL HEALTH ICT 8I7]1 3M <br />