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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit No. __ ------------------. <br /> ------ ----- <br /> - <br /> --------------------------------------------------------- This Permit Expires ] Year From Date Issued 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 Countyy Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION .-__ I. /�- -- ----0 127-1.0/ !/4/'_---A4I-------------------------CENSUS TRACT ---- r <br /> Owner's Name t---V-`--------� i 0--fV---do------------•------------ � - ----------- ---Phone ------------------------------------ <br /> Address , - / - -1 tafV-----I-Sf-------. City -Ri Gf±�-----�------------ -- <br /> Contractor's Name -_ --------------------------- ---------License Phone <br /> Installation will serve: Residence [M Apartment House❑ Commercial❑Trailer Court ❑ <br /> Motel ❑Other ---------------------------------------•---- <br /> Number of living units:----,-____ Number of bedrooms 2-------Garbage Grinder ------------ Lot Size ---------------- <br /> Water Supply: Public System and name ---------------------------------------------- ---------------------------------------------------------------Private FT <br /> _�Chpracfer of soil to a depth of 3 feet: -Sand❑ "Silt❑ Clay ❑ Peat❑ Sandy Loam -C] - Clay Loam ❑- <br /> Hardpan ❑ Adobe ❑ Fill Material ----- ------ If yes,type ---------------------------- <br /> (Pl'ot 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 f ] SEPTIC TANK f ] Size___ -----------_------------_------_--- ________ Liquid Depth _____-----_-----_-_,_-. <br /> i <br /> Capacity -------------------- Type ------------------- Material------- -- - No. Compartments ------•------•-------- <br /> iDistance to nearest: Well ------------------- ----------------Foundation ..-- ---------------- Prop. Line ---------------------- - <br /> LEACHING LINE [ ] No. of Lines ------------------------ Length o each line_._-__._._-____ ________ Total Length ---------------------------- <br /> 'D' <br /> ____---_-_ 6 <br /> 'D' Box ------------ Type Filter Material - -----------------Depth Filt r Material --------------------------------------. ...~ <br /> Distance to nearest: Well ------------------- ---- Foundation _______ _____ ------- Property Line. -.--_---_---_-_-----...- <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter -------- ------ Number ---------- ----------------- Rock Filled Yes ❑ No i❑ 1 <br /> r Water Table Depth 0-- ---------------------Rock Si e -_-___..____---------------•---- 0 <br /> Distance to nearest: Well ---------------- ----------------------Found tion -------------------- Prop. Line -------------------__ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# _-.____-..__ n_________ ____________________ Date - -------__----__--..__-_---_--_.) 0 <br /> Septic Tank (Specify Requirements) --------------------- -------- ---------------------------------.F---------------------------- <br /> Disposal Fie d (S ecify Requirements) ------------------------------ --------------------------------- --------------------------------- --------- <br /> _= fid: 1= - ----------G e------- �........ .��------ Z;� <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 <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 /> "1 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 /> 1 <br /> Signed ____ _ __ ___ __ ___ __ Owner <br /> ----- -------------- - ---------- <br /> BY ----- --- -- - -------- /L. --------------------- Title --- -------------------------------- <br /> i (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> t <br /> r APPLICATION ACCEPTED BY ---�C �V--------------------------------------------------------------------------- DAT#: <br /> BUILDING PERMIT ISSUED --------------------------------------------------------------- -------DATE ------ ------------------------------------ <br /> ADDITIONALCOMMENTS -- - ----- ------------------------------------- -- ---- ---- ------------------------------------------------- --------------------------- <br /> r <br /> ---- --- ------ ----- --- ------ --------------------- --- -------- ----- ---------------------------------------------------------------------- ---------------- <br /> ----------------------------------- ---- -- ---------------- -------------------------- ---- -- <br /> F Final Ins• ----Date <br /> w ---_-------_-_- ___--- ----7 :_�.4 V <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />