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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> Permit No. <br /> --------------------------------- -------------- (Complete in Triplicate) <br /> - -----=- ----------------------------------------- Date Issued <br /> ------ --------------------------------------------- <br /> This Permit Expires l 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 /> desr,ribed.,Thisapplication is.made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> $ �i7yt3 .- Gotc�r +�n °� fi �_b___ /. �. +`�ti - CENSUS TRACT __S-` _... <br /> !�_ <br /> JOB ADDRESS/LOCATION .--- <br /> . ----- ------------------------ Phone a <br /> Owner's Name ---�--�,�r1".--------- - ' . �R' ------•----------•-••- <br /> Address ---------------!Y-` ,S'1� � <br /> r?f rr _ ----�-'�C--------, �!c=-� City -=----.... ---•- - --------------- <br /> Contractor's Name --� '" <br /> ----------------------------------=>-------.License # ---------.-------------- Phone <br /> Installation will serve: Residence ❑Apartment House F1 Commercial ❑Trailer-C o <br /> Ui <br /> Motel ❑Other ----------------------- -------------------- <br /> Number of living units:----- ----- Number of bedrooms ____________Garbage Grinder ------------ Lot Size __----------------------------------------- <br /> -------- <br /> ------ -- <br /> -- <br /> - -----•- <br /> Private <br /> Water Supply: Public System and name --------------------------------- I -------------- <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam <br /> Hardpxff f I -dater❑—fill-Material=,__ if-yes;-type–�-�`-=�""— ` <br /> i (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 /> 01. Li 7 <br /> PACKAGE TREATMENT [ ] SEPTIC TAMC*0 Size_� -�`_6-- '--��-`-Z-------------- quid Depth _'.�- --- <br /> Capacity Type?- --- Material No. Compartments -y..........:.... M, <br /> Distance to nearest: Well ___- _G---------------- ------Foundation __/9------------.- Prop. Line __:�___:__:..------ <br /> Z- ___-______-- Length of each line-- _ a I------------- Total Length :f - --------------- <br /> LEACHING LINE No. of Lines -------_____ en g <br /> / ---------------- <br /> 'D' Box •�-�- Type Filter Material _fa-_�?____.___Depth Filter Material .-��--'-.----- •--�-- <br /> f Distance to nearest: Well ---S_��________-___ Foundation -[a_________________ Property Line. --------------•-=---- <br /> SEEPAGE PIT [ Depth --- -- -------- Diameter -�_�__`_--- Number -------- Rock Filled Yes,) No I❑ (`L <br /> ---------- --Rock Size -_ 'a-----�------------- <br /> i Water Table Depth --=:�±�------ -------------- � <br /> .Foundation /-b-------------- ProLine -----.. <br /> Distance to nearest: Well __f�--------------------------• - � p' <br /> Date ----------------------------------) <br /> ---------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit_# -------- ----------------------------------- � <br /> f ------- <br /> Septic Tank (Specify Requirements) ---- --------- ------------------------------------ ------------------- <br /> Disposal Field (Specify Requirements) --------------- ---------------------------------------------------------------------------------------------------- <br /> ' -------------------�-----;-------------------------------------------- <br /> -------------------------- <br /> ------------------------- - -- - - <br /> - .. .... -------- ----- <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"5an Joaquin l3 <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, I shall not employ any person in such manner <br /> as to becom subject t Workman's Compensation laws of California." <br /> SigneOwner <br /> --------------------- <br /> Title ----------------- --------------- -------------------------------------- <br /> BY ---------------" -------------- ------------ <br /> (If other than owner) <br /> FOR .DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY __- ". _ ------------------------------- DATE -�:/4_-Z1--- --•--------------- <br /> r-r�-�f <br /> BUILDING PERMIT ISSUED ---- -------------- ------------------------------------ --=------------- DATE <br /> ADDITIONALCOMMENTS -- --------------------------------------------------- --------------------------------------------------------------------- <br /> --------------------------- <br /> ' -- - -------------- ------------------------=----------------------------------------- ---------- ---------------- <br /> f-- ------ <br /> Final fns ection b Date --------------- ----------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />