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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> Permit No. _ _ _"5�y_ <br /> (Complete in Triplicate) <br /> ' - Date Issued <br /> r <br /> This Permit Expires 1 Year From 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 /> JOB ADDRESS/LOCATION -2�- -- - -- - <br /> ;:,, ... -----CENSUS TRACT ------------------------- <br /> - a 3 M <br /> Owner's Name / . _ _ -: ---- <br /> P one. <br /> F ---•------ <br /> Address ----- -- --C -�9_11 A--- - - - ------ - -- - - ------- ---- ------------ <br /> City --------------------------- <br /> Contractor's Name -'7--�-` -----,---------.License # L Phone -----------y------- --------- <br /> Installation will serve: SResidence ❑Apartment House°171 Commercial ❑Trailer Court '❑ <br /> V. <br /> Motel ❑Other ------ ------------------------------------- <br /> Number of living units:-----I----- Number of bedrooms ----2"'-Garbage Grinder --.--------- Lot Size _ = — ---------- <br /> Water Supply: Public System and name -------- -------------•-------------. ---------------------------------------------------------------------Private E!r— <br /> Character of soil to a depth of 3 feet: Sand'❑ silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> F Ile Hardpan [✓Adobe ❑ Fill Material ------------ If yes, type ----- --------------------- <br /> tf <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 /> f f i � f <br /> PACKAGE TREATMENT [ ] SEPTIC TANK:[i'� Size-I/ -__ ------- -------------------- Liquid Depth _----_--__----.---_-. <br /> jZ��s -----•----- <br /> re Well Foundation No. Compartments <br /> Capacity -------- --- Type---- T e - ---------- -- Material- ------- <br /> E o <br /> N, Distance to nea s : ---------- �' - �� --------. Prop. Line '-- <br /> ------ <br /> LEACHING LINE [e No. of Lines -----r -------------- Length of each line.------ '"D-� ----a----Total Length lC�- -----_..-_.____ <br /> i__j - <br /> [ 'D' Box -- _ Type Filter Material -- -r_-__--Depth Filter-Material .----.-- - ---------- -------- -------- <br /> Distance t nearest: Well -----S-0--;--------- Foundation ,1;U---0;------- Property Line. __tas�---------------- C <br /> SEEPAGE PIT [e Depth ----;;4------ Diameter .---; 3- t- Number ------- ----------- Rock Filled Yes No i❑ <br /> Water Table Depth -----------0---------------•--------=--------Rock Size --- x f .• <br /> r <br /> iDistance to nearest: Well ---------------------------------- ----Foundation ----------------`-- Prop. Line ---------_------•--•-- <br /> i REPAIR./ADDITION(Prev. Sanitation Permit# ----------------------------------------- -- Date ---------------------------------- <br /> Septic Tank (Specify Requirements) -------------------- -------------- <br /> Disposal Field (Specify Requirements) ------------------------------------------------------------------------------------------------------------------------------------ <br /> --------- --------------------------------------­---------------------- <br /> -------------- <br /> ------------ <br /> ' <br /> (Draw existing and required addition on reverse side) <br /> 1 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 /> 'as to becom biect to Workman's Compensation laws of California." <br /> Signed ---- ------- Owner <br /> I <br /> 1 <br /> By Title - •Pry-t'-� sr ! <br /> ---- - ------------- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY .-- - - - -------------------------- ------------------------------------• DATE ..------------------ <br /> BUILDINGPERMIT ISSUED ----------------------------------------------------------------------------------------------------- ---DATE ------------- ----------------------------- <br /> ADDITIONALCOMMENTS --------------------------------------------------- -------------------------------------------------------------- ---------------=---------------- ---------- <br /> ------------------------- ------------------------------------------------------------------------------------------------------------------------------ <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------_-------------------------------------------------- <br /> ----------------'--------------------------------------------------------------------------------------------------------------------------------------------------------------- ----- <br /> ---- --- ------- - - - - - - - - - --- ------- <br /> FinalFinal <br /> Inspection by: �'% -. --------- --- -------------------- ---------------------Date/7.3 �. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />