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FOR OFFICE USE: <br /> APPLICATION FORJANITATION PERMIT <br /> Permit No. _'x-1 ----------- <br /> ---------- / <br /> (Complete in Triplicate) <br /> I--------------- ----------------------------- <br /> _.____-__-__ This Permit Expires i Year From Date Issued Date Issued _4 <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. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION ---------------------------------------------------- /eIP�L__ �D..�LU-c /__-.------CENSUS TRA <br /> Owner's Name -------D?pN------C 0;515---------------- <br /> ---------------• ---- ----- ------P one---•------•-- --------------------- <br /> Address --------- ------------------------------ - Ci <br /> Contractor's Name --------- •-------------� ------------------------License # _PP. __P--- Phone -- <br /> r' <br /> Installation will serve: Residence P Apartment House-E] Commercial:❑Trailer Court ;❑ ; <br /> Motel ❑ Other - -------- --------------------------------- <br /> Number of living units:---.-/.... Number of bedrooms __�__---Garboga Grinder ------------ Lot Size -_ <br /> -------------_-_--- <br /> Water Supply: Public System and name --------------- ------------------------------------------------------------•------------------------•---------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ .Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe T' Fill Material ------------ If yes, type ----------------I----------- <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_____-6-_X__5- __k-A?__-___-__-- Liquid Depth ----- - //-,- __ <br /> i <br /> Material---------------------- No. Compartments _-�-._-_- .. <br /> —Capacity <br /> i - <br /> Distance to nearest:; Well _--__.--__________________________Foundation 3_40-------------- Prop. Line ...................... <br /> LEACHING LINE of Lines__.__€�_ ____________ sLength of each line_ _ . _- i U <br /> { l Nb: � ' Total Length . <br /> D 'Box ......I--- Type Filter Material f�Xc��_Depth Filter: Material ____�, _�-__._ <br /> Distance to nearest: Well -------------------------_Foundation J, ----------- Property Line. - -- ............... <br /> SEEPAGE PIT [ ] Depth -------------------- Diametef ---_____.--.--- Number ----------------- _________ Rock Filled Yes '❑ No C] <br /> i Water Table"Depth ------------- - -__----__Rock Size ____ .-_.____..___ <br /> -------------- <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line --------------.-_----- (� <br /> REPAIR/ADDITION(Prev. Sanitation Permit# --------- ---------------------------------- Date __---_-_____:____________________} <br /> SepticTank (Specify Requirements) ------E---------------------------------------------------------------------------------------------------•------------------------' •---- <br /> DisposalField (Specify Requirements) -------------------------•-------------------------------------------- ------------------------------------------------------------- <br /> a <br /> ____ d `-' <br /> ------------------------------------------------------------- <br /> - - - - ---------------------------------------------- 111 <br /> (Draw-existing and required addition on reverse side) <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, State Ldws; and-CRulet-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 for which this permit is issued, I shall not employ any person in such manner <br /> as to become subject t War man's Compensation laws of California." ' <br /> Signed --------�- r - -f------ - -- ------------- ---------------------------------- Owner , <br /> t <br /> BY --------------------- ------------------------- Title--------------------- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY --- --- --------------------------- ----------------------- DATE ---------------- ------------------------- <br /> BUILDING_.PERMIT-ISSUED-------=� - _ ------------------- -----------------------------------------t- -----DATE-_..,_:_--------------------- ------ <br />_,_ ADDITIONAL COMMENTS <br /> ------------------------------------------------------------------------------- <br /> = = <--- ----------------- <br /> -- - <br /> - ----------------- <br /> Final Inspection by:' ------------------------------------r` Date _.. 2 <br /> SAN JOAQUIN LOCAL HEALTH ISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />