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FOR OFFICE USE APPLICATION FOR SANITATION PERMIT <br /> Permit No. ...75..- -- -•' <br /> ....................................... (Complete in Triplicate) i <br /> .................................... This Permit Expires 1 Year From Date Issued <br /> Date Issued ..�.`-��.... <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 /> r JOB ADDRESS/LOCATION .. ....... .......-c.--r��....��.: ... __ X-!T"' _..._.��.., ..-4?�71.G'`CENSUS TRACT ..................... <br /> Owner's Name <br /> n�fJ411A.�4...- v.............................._.-....-......-, ..........'•....................Phone ..............................._... <br /> Address .......pt.f_�ri-.f1-- Q..-. 1k.. C?I--------------- City � ��? .-......-.. ......................... <br /> . <br /> r Contractor's Name ._. _ ... . 5'----` ..... "` . .......License # tbp, . 2..... Phone ..............._............. <br /> Installation will serve: Residence [Apartment House❑ Commercial oTrailer Court 0 <br /> Motel ❑ Other ................ r .....-•------------- <br /> Number of living units:......).... Number of bedrooms .....'T..Garbage Grinder ............ Lot Size -.- '--/------- <br /> Water Supply: Public System and name ------------------- --....._.. ---------------- ................ ----------...-----------------------..Private [S <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan Adobe ❑ Fill Material ........-... If yes,type............................ <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------------------------------------------------ Liquid Depth ----.-.......--.-...--...- <br /> Capacity ---------------- - Type -------------------- Material-------------------. No. Compartments -......._............ <br /> Distance to nearest: Well ------------------------------------Foundation ...................... Prop. Line ..........._......... <br /> LEACHING LINE [ ] No. of Lines ........................ Length of each line............................ Total Length -........................... 6 <br /> 'D' Box ............ Type Filter Material --------------------Depth Filter Material ------------......................,......... O <br /> Distance to nearest: Well ........................ Foundation ........................ Property Line ....................... <br /> SEEPAGE PIT [ ) Depth ............. Diameter ................ Number ..._ ................. Rock Filled Yes ❑ No ❑ <br /> Water Table Depth ..............................._...............Rock Size ................................ Z <br /> Distance to nearest: Well ........................................Foundation .............. Prop. Line .................... ' <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ..................................I <br /> SepticTank (Specify Requirements) ......... ......... ............................•..................................�_}}--...-.-.�-.-...---..._ _------------------------- - <br /> Disposal Field (Specify Requirements) ------- -- -- -- ._.-_...._ - --- ----- ^:lz. .__.- ......._.---le .-_. <br /> VVVV- <br /> ------------- <br /> -�! - -- ------------ ----- --------------------- - s <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 laws, and Rules 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, 1 shall not employ any person in such manner <br /> y as to become subject to Workman's Compensation laws of California." <br /> Signed ..........--------- --r.l----------------------- --- Owner <br /> B <br /> y N C-. <br /> !r�'^ - Title ..(Z4n�ils� tw............ <br /> _ (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ...... ....ee+JV---------------- ........................................................... DATE -...y ` 0 �l'J-----.......... <br /> BUILDING PERMIT ISSUED /+ - ....-- D <br /> ATE <br /> . ................ .................. <br /> ADDITIONAL COMMENTS - . -------••------•--•- ...... <br /> ....................... ..--------------- ..........--...............................--•-....................................................................................---------•-- .......... <br /> ` -- .............. •----- -•- . •- -.,....----•--=------------------------------------•--...... ....-------..... ---------------------__-... ---•- <br /> _.. -- <br /> Final Inspection by: .. --- ------•. ..-- .--...--...........................-------------•--------..-...--..-.-_...-.......Date ......F �jj ?'... <br /> ` SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E.H.13 241-68 Rev. 5M 7/72 3 M <br />