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FOR OFFICE USE: <br /> APPLICATION 11FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit No: -'"______ <br /> it Date Issued -40�=_7- 3 <br /> -----------___.____..___________._--------------- This Permit Expires i 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. 5.49 and existing Rules and Regulations: <br /> 1 . <br /> JOB ADDRESS/LOCATI <br /> Owner' Q___-_._ � = zS�-7 <br /> , -�----- �-C �..�---- T --TCENSUS� TRACT _ - ------------- <br /> Owner's Name <br /> !! <br /> " <br /> • P <br /> hone <br /> Address City <br /> ------ ----- -- - <br /> Contractor's <br /> Name ------- _ - ---__ .License # J - $._Y Phone------------------------------- <br /> Installation <br /> _____________________ ___ ____Installation will serve: Residence Apartment House-F] Commercial ❑Trailer Court ;❑ <br /> f Motel ❑Other ------ ------------------------------------- <br /> Number <br /> ----I------------------------------------- <br /> Number of living units:-------- Number of bedrooms ---Ih _Garbage Grinder _________ Lot Size ____________ ___________ _ ____________ <br /> WaterSupply: Public System and name - -------------------------Y-----•--------------------------------------•-•----------------------------- ------Private ) <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt E] Clay E] Peat❑ Sandy Loam -E] Cay Loam .E-] <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 seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT SEPTIC TANK ---------------- Liquid Depth _______________.___,____ <br /> [ ] � ] .i Size-----------------------• - - <br /> Capacity --------------------- Type ------- ----------- Material---------------------- No. Compartments ...................... <br /> Distance to nearest: Well ____ �j <br /> ------------------------Foundation ---------------------..Prop. Line ...................... <br /> LEACHING LINE [ ] No. of Lines _______________________ Length of each line---------------------------- Total Length -_-__.--....____--_-._-___-. <br /> 'D' Box ------------ Type Filter Material --------------------Depth Filter Material ---_--------------------------------------.- <br /> n <br /> Distance to nearest: Well <br /> --=t------------ Foundation ------------------------ Property Line --------------------_- <br /> SEEPAGE PIT [ ] Depth ----------- -------- Diameter ------------- Number ---------------------------- Rock Filled Yes ❑ No ❑ <br /> Water Table Depth ------------------.11------------------=--------Rock Size ------------------ ------------- <br /> Distance to nearest: Well ------------ ------Z_____ --_--:-M::Foundation`-------------------- Prop. Line _-_.____.--__-.------. <br /> REPAIR/ADDITION(Prev. Sanitation Permit x# --------------------t---'---'---------- - Date ---------------------------------- <br /> Septic <br /> ---- --• -•---------- <br /> Septic Tank (Specify Requirements) _______________________ <br /> Disposal Field (Specify Requirements) - �(_ �. C �Q.L- ---�__-- - _-- �x- z.--------g�--------_ <br /> t <br /> ,g ti <br /> --------------------------------------------------------------------------------- ----------I--------------'--"'-`------------------------------------------------------------------------------------ <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that I have prepared this application acid tkat th work will'be done in accordance with San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquinlocal Health District. Home owner or licen- <br /> sed agents signature certifies the following: E� <br /> "I certify that in the performance of the work for which tFtis 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 - ----------------- ------- Owner <br /> I <br /> $ i �------ Title -- - -� ---------------------------------- <br /> y ---------- --- ------------------- - • �. <br /> (If other than owner) i <br /> FOR .DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -- - - - -- ------------------------------------------------------- DATE ------------------- <br /> . <br /> 11 <br /> BUILDINGPERMIT ISSUED -------------------------------------------------11----- ---------------------------------- --------------DATE ------------------------------------------- <br /> ADDITIONALCOMMENTS --------------------------------------------------1I-- ------------- ------------------------------------------------------------- ---------------•----------- <br /> ----------------------------------- ----- <br /> ------------------------------------------ <br /> ---------------- -------------- --- $il_ <br /> -------------------------------------------------------------------------- <br /> ---------------------------------- <br /> - - ------------------------------------ - ---- -- --------- -- ---- ----- -- --- -- <br /> Final Inspection by: ✓l.L-� f�---------•------------------------- ----------------Date - /. ---3---------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'b8 Rev. 5M. �� <br />