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f.FOR'OFFICE USE.- <br /> APPLICATION FOR SANITATION PERMIT <br /> _.....;..............................I..... - ............ <br /> ................:........................................ <br /> IC*mplete in Triplicate) Permit No <br /> This Permit Expires fiYear From Date Issued 76 <br /> bate Issued _����_: <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construd and install the work herein <br /> described. This application is made in compliance with County Ordinance No. 5149 and existing.Rules and Regulations: <br /> JOB ADDRfSS/LOCATION,2..G.. __...-� :I/,P- .Ch.. • <br /> �_...... CENSUS TRACT ...C.� ........... . <br /> .............. ........ .......Phone /r <br /> Owner's Name .---•_�.e7 . '�/Il� ®3.� c�:��......_._._. ............ <br /> � . ... .���/..'.':�1/:�•--- <br /> Address <br /> 5 <br /> ._' - -_-- ------ - �............� <br /> y � � . . - .....-.---- <br /> Contractors Name _.... f74 ense # - ---- Phone �. . .. ... . <br /> .......... t _ L <br /> Installation will serve: Resid <br /> A. <br /> ❑Apartment,Hous'e1:] Commercial❑Tralle�r-:Court E] <br /> Mote)' Other_ ,C� ,/� - 9 L ve . <br /> Number of living units:....,..... Nu of bedrooms -��._._.__Garba§e Grinder .. ._ Lot Sixe �1,�, .., .s '' --•--=----. <br /> Water Supply: Public System and name <br /> .....---..................11_.......................... .................... ----•------•--_------ <br /> ....._ r <br /> P ivate �,�-�•" �� <br /> Character of soil to a depth of 3 feet:; Sand Slit Or Clay ❑ Peat❑ Sandyk Loo ❑ Clay Loam-� <br /> I Hardpan❑ Adobe❑ Fill Material ..........if yea,ty e .............. ..:... <br /> (Plot pian, showing size of lot, location of system if-"elatinto well . build'�ngs, etc. musk,be placed on reverse side.] <br /> NEW INSTALLATION: (No septic tank or seepage ,pit ;permitted if public sewer.is avaflad `e within 200 feet,] <br /> E PACKAGE TREATMENT [ ] SEPTIC TANK{ I Size.. Depth ........................... <br /> Capacity � .. _�xypeY �a. �;. MatercdC'-•----: No. Compartments .. ......:�- <br /> J _ <br /> Distance to nearest: Well ...................Foundaf*n,_,eOf: .........Prop. Line _..s .. ...... <br /> I/ s ► <br /> �. LEACHING LINE { j No. of Lines ..._.:-��:�__-.. Length ,of each tine-__:--� >:.�!.�:�. Total' Length ............ <br /> 'D' Box Type Filter Materia %' ....Depth Fi Mate I . /p...... ........... <br /> Distance to nearest: Well ....S_f�_.:t:.+.4 Foundation?._.f j3 ......... Prope Line ..... ---►"'`......... <br /> 86EPlT { ) Depth .._ ...- -_ --. Digmet Number .....- ockyilledY No 0 <br /> ...........7 <br /> I Water a De ._..... -=--...:...: o ae ......................:.:: <br /> k ' Distance to nearest Well + ::Foundati �: # � '` - <br /> _..._.... ........ Prop. Ino., .. <br /> ,...__ �r <br /> REPAIR/ADDITION IPrev. Sanitation Permit# --_••---.---- --------- ----•....... •--... Date .................. <br /> ..... -�-�----------------1. <br /> Septic Tank (Specify Requirements). . <br /> Disposal Field (specify Requirements) <br /> -••------•-•........... - .......... _._.... !............ <br /> . <br /> ------------------------------------- ---- --- --:....... ._,.................................. <br /> ................................... <br /> ..... •...•. ... ............ <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 w 1h`San'loaquln <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Hea4 Olstrict. Ho a owner or licen- <br /> sed agents signature certifies the following: f, <br /> k "I certify that in the performance of the work for which this permit is Issued, 1 shall not employ any.person in such manner <br /> as .to become subject to Workman's Compensation laws of California." <br /> Signed -------------•---------------------•--• --------- -----• --------•-------•--- Owner <br /> By -------------•• -••------•-•--..__ _.-------- . --•• --------------- Title ................ -- <br /> (if other than owner) <br /> k F 0 RTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ------ M—----------------------------------------- DATE :,...rc. ._17A <br /> Z = <br /> BUILDING PERMIT ISSUED ...... ---- ° <br /> Lti . �• `'•-.-..`r '-------- -..DATE ------------------ ........ -------------- <br /> ADDITIONAL COMMENTS ---..- .�?1 .-:-�C�2lZ��.�DJ' dU.t�,� � E� .�lT ':f.p.. <br /> --•---------------------------------------------- — <br /> .2111 <br /> ----------------- —---------• - ---.. -----•------• -------- :-------- --------- •---•-•--- - ----...-------...------._.........._......-- ............... ...........•............ <br /> --- •. -_. .................... <br /> -- - - - - - -- - - - <br /> Final Inspection b ....._.._...Date ...�. <br /> fT 7,�................ . <br /> P y-- ---------- ----- <br /> EH 13 24 1.68 Rev. 5H SAN JOAQUIN LOCAL HEALTH DISTRICT 8/711 3M <br />