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FOR OFFICE USE- <br /> APPLICATION FOR SANITATION PERMIT <br /> /-� -74. - e Permit No.. <br /> Y (CompleteTriplicate). 4 <br /> ----- --------------- <br /> ---------- <br /> { . <br /> ---- --�----------------------------- <br /> -------� j[ ermit Expires Year From Date Issued � -------"��"�-----� <br /> This P p Date Essued <br /> 6 <br /> Application is hereby made to the San Joaquin local Health District for a permit to construct and install the iwork herein <br /> described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> ---.CENSUS TRACT ----------- "------------- <br /> JOB ADDRESS/LOC ON .----"�.-_--- .-7-,---- 1-:---- ---- _ <br /> /1 ----• ------------ <br /> Owner's Name le�NJ 4,� � ---- ------------- --------------- <br /> - Phone . <br /> ,� gyp _ 1 <br /> s _ C G ��¢ �-���'-- . ---- --- City <br /> Address ---------- - - �--- -.n-- - - - - -- - . _ ------ <br /> Contractor's Name ---- t`��- -----�-------.License # o?•a`"ylZ PhoneW3/- <br /> Installation will serve: ResidenceApartment House❑ Commercial ❑Trailer Court ;E] <br /> n- Motel ❑01 "------------------------------------------ t r l s <br /> 1 Number of living units:____ Number of bedroa ---- --•Garbage Grinder --- -------- Lot Size _ -x --------- ------- <br /> I ] i <br /> � ------------------------------` � � - --- -- '--=--------------•-----------------------•---------•-----Private <br /> Water Supply: Public System and name <br /> - t � <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt C1 Clay ❑ Peat E] Sandy Loam ❑ Clay Loam <br /> k { Hardpan ❑ F AAdobe)< Fill Material s__ If yes, type ___--______`______"------- <br /> ' F buildings, etc. must be placed on reverse side.) <br /> (Plot plan, showing size of I'ot, location of system in relation to wells, j <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> lJ� <br /> Liquid Depth -------- <br /> No. <br /> ---- <br /> PACKAGE TREATMENT j ] �-SEPTIC TANK'[ ] Size--------------------- ------------- ---------- q 1. p . <br /> Capacity ,_t:..:i ,TY.Pe k=m,a :---- -- Material i_. No. Compartments \ <br /> i <br /> E ;foundation ---------------------- Prop. Line -----------------•---- <br /> Distance: to nearest: Well _-_------------------"-----_-•--- <br /> JI <br /> ` LEACHING LINE [ ] No,,;of 'Lines ------------- ------ Length of each lire --------------------- Total Length -"----- ---------------- <br /> D Box Type!Eitfier-fVlaterial `""---`---,� '_: Depth Filter Material ---------------------------------------••- <br /> Distanc Ito nearest: Well ------------------•----- Foundatioti ---`---""_°"Property Line --------- <br /> Diameter.—PIT Depth 111 t. '3 ---.Rock,.Filled Yes No <br /> [.) p Diameter_ -- ._. Numberr_.ti-------------------- ❑ �❑ <br /> 1-- - -- ""---- I . <br /> I �,� <br /> Water Table Depth -------- --------------------- -------- ------stock Size :�=_--- _-------•-i <br /> Distancelto nearest: Well _ -----------------------------------------Foundation s_----- op.� Line ___.__...-..-- <br /> sf -------- <br /> ---------------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------- -------------------- Date,."- : ;--------) <br /> Se tic Tank (Specify Requirements) - ---- --- ------- _ <br /> P y q 1r---- <br /> ` rs� f'------'- <br /> ` Disposal Field (Specify Requirements) _ - --:: �� ` �+ =.rf """ d <br /> F ` 9 cif.fji� ---- ------------ <br /> - <br /> - <br /> -- _--�ex <br /> ----------------------------------- ---------------------------------------- — <br /> (Draw sting 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 LocaVHealth District. Home-owner cr 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 beSNne subject to orkman's Compensation laws of California." <br /> c t �',Et�_f� --- = ------ :Owner.;t <br /> Signed = <br /> BY -- --- Title_*_tr —----------- --------------- <br /> If other than o r) <br /> I FOR .DEPARTMENT VISE ONLY <br /> APPLICATION ACCEPTED BY .-- ------------------- DATE <br /> BUILDING PERMIT ISSUED ---- -- -- DATE <br /> ADDITIONAL COMMENTS ----------------------------- - -------- ---------------------- <br /> ------------------ ----------------------------------------------------------- ------------- - ==m ------------------------------------------------------------------- <br /> f __ __ ------ <br /> Final Inspection by: 1_ __ � �.,r ,, <br /> Date Q'---- --- --•-- / <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M` <br />