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FOR OFF1gl=tSE:,A <br /> APPLICATION FOR SANITATION PERMIT <br /> ........... ...............:................... o <br /> lCornplete In Triplicate) <br /> Permit N . ...�.�._��`� <br /> ................................... <br /> ...... This Permit Expires 1 Year From Date Issued Date Issued <br /> Application is hereby mode 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 unty Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION A/ENSUi TRACT .......................... <br /> Owners Name ..- ..:.:..............Phone�� ....7.77 .. <br /> Address .... ...:City .., /. /s ...................................... ... <br /> Contractor's Name ��71 �..............•-. ....:........License # .......441-4...... Phone .-/�1_...._--.---•--_ <br /> A Installation will serve: Residence©Apartment House Commercial Nftraller Court ❑ <br /> Motel ❑Other................................... ......J� : .. 4 r <br /> Number of living units:...:....... .Number of bedrooms WA.•.Gorbage Grinder .N.d,. Lot Size-_...Oe. . . ., _----s...........:. . <br /> Water Supply. Pubic System and name ................... cr..:................Private <br /> Character of soil to a depth of 3 feet: Sand (Si1n. <br /> day Peat Sand Loarn`. Cla toam <br /> ]� 0 y0 0 Y y D <br /> Hardpan 0 Adobe Q Fill Material ............ if yes,type............................ <br /> t <br /> (Plot plan, showing size of lot, location of systeh�-lh`natation"to wells,-buildings, etc. must be placed on reverse side.)l ) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) �1 <br /> PACKAGE TREATMENT [ J"A , SEPTIC TANK[ J Size.. 1.5: 1.1� .............. ........ Liquid Depth ..................... <br /> �.f. Capacity IW ....... Type __..•---:_---- Material e'o"elZek No. Compartments -----Z-....... 6 <br /> .Distance+to nearest:-Wel! ....:.......................:.......Faunciafion <br /> _ Pro Line <br /> LEACHING LINE ( J No. of Lines -----................::. Length of eachline.._._._.._.............__... Total Length V) <br /> D' Box Type Filter Nli ter iol.............. ...Depth Filter Material <br /> ADistancelto nearest: Well ...... ............... Foundation .................... roperty Line ........................ <br /> �f. ..... Diameter r f <br /> [ } Depth _. 'lG_.. '. �, Rock Filled Yes ❑ No <br /> SEEPAGE PIT _... Number ! <br /> 'Water Table Depth .................. <br /> _....... ------- ------ ............Rock Size <br /> Distance to nearest.Weli ---,1 ��?. ....Foundation Prop. Line .. ..... <br /> REPAIR/ADDITION(Prev. Sanitation Permit ... Date ........... } <br /> Septic Tank (Specify Requirements' ..--.....e .......... <br /> � ecifY Re virem . # rDis <br /> Disposal Field lS +C. <br /> - � ------•--•-••............................................. ............................... .......................... --••-=- <br /> ..................:......................... ................................................--------- <br /> (Draw existing and required,addition on reverse side) <br /> I hereby certify that 1 have prepared this application land 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 HeaI&Dislrici. Horne 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 /> i as to bM' a.�ublect to Workman's Compensation .laws of California." <br /> Signed `�..-. : J � Owner <br /> t <br /> By ----- ------------------- ---------------------•---- -------------------------------------------------- J:itle ----•----- --- <br /> (if other than owner) <br /> FOR IMPARTMENT USE ONLY - <br /> APPLICATION ACCEPTED BY . ........_ .--•................................•--._DATE <br /> BUILDINGPERMIT ISSUED _---------"------ ----------------------------------------------------------------------•-•.__._._.......--•---------------•----..._............DATE .--- ------ <br /> ADDITIONALCOMMENTS ---------- ----•-------------------------------------------•------...--------------•----------------•------------------------------:..._._..:...._.....----•- <br /> ----------- -------------- ------------------ ---- ------• -•--•••..... ..... .... ..------ .......--•-----..-. - ...............--. --------------------------------------- <br /> ..... .....- .....I.. ......... _..._.........- . <br /> ----- -- - <br /> Final Inspection by. --------- ----- ----------- •---......--•-•-.. •-------- ..........Date <br /> EH 13 24 1-68 Ike <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M <br />