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FOR OFFICE.' '0 APPLICATION FOR SANITATION PERMIT <br /> SJ <br /> ��s=• 17a------ = -_------ C� <br /> ----- --- ---------- �-- Permit No. - <br /> {Complete in Triplicate) q <br /> ----------------------------------- ------------------- 1 <br /> --------------------------------------------------------- This Permit Expires 1 Year From Date Issued <br /> Date Issued � �-3' . <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 - ---------- -------------------------------CENSUS TRACT -------------------------- <br /> If <br /> Owner's Name ` ----- -------------------------- ---------------=------ Phone ✓ ,6'-!_-�7- <br /> Address ------------------76,63- city= ! G--------------- <br /> Contractor's Name,_,__­ <br /> ame ------ a'w�--------------License #167.. -------- Phone YKJ"?6_4.7 <br /> Installation.will serve: Residence artment House Commercial : Trailer Court <br /> ;./ <br /> ` �"t V*-rl Motel ❑ Others--------------------------- ------ <br /> Number ofItivng units:_-___/--- Number of bedroo s - 4Ga a e Grinder -------- --- Lot Size -.---�� r---------------- <br /> Water <br /> ##SuPP .' C <br /> Pub licSYtem and name ------------------------•.. fJ--. -1 ----------------------------------------------------------------Private <br /> Supply: Pu • s <br /> Character of soil to a depth of 3.feet,:; Said'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam :❑ <br /> Hardpan ❑ Adobe Fill Material ------------ If yes,type _--_____--____-___-__ <br /> �c[PLat, plan, showing size of lot, location of—system n-.relai on to wells, buildings, .etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit-Permiite�dif public sewer is available within 200 feet,] <br /> PACKAGE TREATMENT SEPTIC TANK' size d --- _- <br /> { 7 { aLiquid Depth <br /> .. .ti <br /> Capacity -------------------- Type ------ ------------- Materi&- ----------- No. Compartments ----------------- <br /> Distance to nearest: Well __+" - -_- tFou�dation-- __-__-__-__-_-Prop. Line ---------------------- <br /> LEACHING LINE [ J No. of Lines --_____________________ 1Length of each line--------------------- �` Total gth'�-----_-_-_-.------_-------__ L�� <br /> D' Box ------------ Type Filter Material --------------------Depth Filter Material ------------------------------------------- <br /> Distance to nearest: Well ___- 1------------------ Found_altion --------- Property Line, ------_-_----_-__---.... <br /> [ ] p - Diameter ---_ Numbe- -------. --_--- Rock Filled Yes ❑ No I❑ <br /> SEEPAGE PIT Depth --- --------- - t - -------- � � -- - <br /> Water Table Depth --------------t--------------------------------Rock Size -----(--------------------•---- <br /> Distance to nearest: Well -----�---------------------------------Foundation J----------------- Prop. Line ..........._--._-----_ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# _------•------------------------------------ Date _-----_-_----_--_--__----_-_------1 <br /> E <br /> Sepf,,ic Tank (Specify Requirements) -------------------- --- ------------ ---- -- ----------------"- --1-----------------------. <br /> Disposal Field (Spedfy Requirements) ------ <br /> --------------•--------------------------------------- ------ -'--- ------------- ---- --- ---- -- ---- ------ -----I---- ---.--------------- <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 with San Joaquin h <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or Hten- <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 to Workman's Compensation laws of California." <br /> Signed ------ , ----------- ------ ----- ----- caner <br /> BY -- -- ---------- - -- -------- - - tle --..- r <br /> 1 s;. t O <br /> (If of er th caner)�� I <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ------ -VJA ---- --- --------------------------------------------------- <br /> ---------------- DATE <br /> BUILDINGPERMIT ISSUED -- --- ------------------------------ ----------------------------------------------------------------- DATE -------------------- -------------------- <br /> ADDITIONALCOMMENTS ------------------------------------------ -- ------------------- ------------------------------------------------------------------------------------------ <br /> ------------------------------------------------------------------ ------------------------ --- ----------------------------------- --------------------------------------------------------------------- <br /> i <br /> --------- -------------------------- -------- -------------------------- <br /> ------------------------------------- <br /> --- f'--- ----------- ------------------------------------------------ 4 - <br /> ------- ---- - <br /> Final Inspection by: ----- -- ---- ------ Date ------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />