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FOR OFFICE USE: APPLICATION FOR SANITATION PEP'"IT <br /> - - - Permit Na. <br /> `4' (Complete in Triplicate) '"� �Q�I�-�",""(" <br /> . -...................................I --------- Date Issued ..f..-1V-u!/. . <br /> --_---_--__---_-_---_------------------------- This Permit Expires 1 Year From Date Issued <br /> Ir 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. 5A9andexisting Rules and Regulations: <br /> _ JOB ADDRESS/LOCATION ..Id - 3-..W-..w. ---IS�C ------------CENSUS TRACT -----------------.------ <br /> Owner's Name --/--)j-,/ e - -7-.>Y--- ---�f--{�.4r-----•-------- hone <br /> Address -----------." w w�Y� - ==-' - -< * .City . --------------------------------------- <br /> -y d <br /> Contractor's Name ----- -- -- - - --------- ----` ., --- .license # - Phone --------------------------- <br /> Installation will serve: Residence PrAApartment youse 0 Commercial[]Trailer Court fl <br /> Motel ❑Other ----------- ------ ........................ <br /> Number of living units:-----J---- Number of bedrooms .._.__Garbage Grinder --- ---------Lot Size -_4aft2.4,Kc�R.....-..-- <br /> Water Supply: Public System and name --------------------•--------------------------- ------- ------•-----=-----•--------------------Private R---- <br /> - Character of soil to a depth of 3 feet: Sand Silt[] Claav❑ Peat❑ Sandy Loam ❑ Clay Loam 0 <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 see ge pit permitted if ubliicc sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK{ Size-� ._fi.�0 /r ✓� . Liquid Depth c <br /> Capacity/. .G Type Material/eOXl--:.-_- N. Compartments sr „__`___,_._ <br /> S � S <br /> Distance to ne(Ffest- Welt -.---.___._Q_.................Founda�ti/o ..--- Line -.-. ..__'__,____ l <br /> LEACHING LINE [ ✓ No. of Lines ..... .............. Length of each line.-..---7-7------. ------ <br /> Total Length .a �FE!._____:__-__ <br /> V BoxYon-earest: <br /> Type Filter Material ._ !2r._.__Depth Filter Material -.--/�--..... ..Distance Well ..._Sqt......... Foundation ------/0._`-------- Property line --,r---------------- <br /> SEEPAGE <br /> --_--_._-.SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No Q 1 <br /> Water Table Depth ----------Rock Size ------- ------------------------ <br /> Distance to nearest: Well ---------------------------.............Foundation ------------_..... Prop. Line ...------___.____---- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ---- .....__.___.__-) <br /> LSeptic Tynk (Specify Requirements) <br /> Disposal Field (Spetify Requirements) --------------------------------------------------••---------- - --------------------------------------•-------••------•-------- <br /> (Draw existing and required addition on reverse side) <br /> LI 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, I shall not employ any pd/rson in such manner <br /> L <br /> as to become subject orkman's Com nsation laws of California_" <br /> >• <br /> Signed .._ .. -..-na <br /> -----------------------------..- Owner <br /> By ... -- _ 3� _ Title .. -- - ... <br /> (If other than owner) 1 '' <br /> le FOR DEPARTME14 T USE ONLY QQ <br /> APPLI TION ACCEPTED BY - - - - --- ----------- ----------------------------- DATE -� 776-! <br /> ` BUILDI PERMIT ISSUED ......._.-------------------------------------- ----------------------------------------------------DATE ------...... ----------------------- <br /> ADDIT�AL COMMENTS - -- -- ---- ------ ------- ------- -------"----- -- ........... ---------------------- ------------'----------------------- <br /> ----------------------------------- ---- -- - ------ ------------------ <br /> ---------------------------------------------------------l5a - - -- <br /> ` Final Inspection by - -- - - -- - - --- -------__--------------------------------------- -------Date ��Q-:. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ` E. H. 9 1268 Rev. 5M <br />