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FOR OFFICE USE: APPLICATION=FOR SANITATION PERMIT <br /> --------------------------------------------------------- <br /> {Complete in Triplicate} Permit No: -7c�---sp__..-.. <br /> ------- - - - - <br /> -------------_---. This Permit Expires 1 Year From Date Issued Date Issued .__ <br /> - - --- ----------------- -- a�-zL <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 .--4p-a_�"___,,r iu -----------------------------------CENSUS TRACT __f9V_--____-____ <br /> � --------t-----�--------------------- <br /> Owner's Name ------�-�- __A -- -----------------Phone <br /> ---- <br /> Address _� s�1� ------ -- --------­­ City, -- -----------•------------------------------------------- <br /> Contractor's Name .--- ----------------------------------------------------------------License # --------- ------ Phone -------------------- <br /> Installation will serve: Residence ❑Apartment House f:] Commercial ❑Trailer„ srt <br /> Motel ❑Other -------------------------------------------- <br /> Number of living units;---)------- Number of bedrooms ____________Garbage Grinder --- Lot Size .__ ___ ____ m4----------------------- <br /> Water Supply: Public System and name ---------------------------------------------- --------------- Private <br /> --- <br /> Character of soil to a"depth of 3 feet: Sand❑ Silt� ❑ Peat El Sandy Loam ❑ Clay Loarn R <br /> Hardpan Adobe ❑ Fill Material ------------ If yes, type ---------------------------- <br /> (Plot <br /> ______________________ ___(Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) 1� <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK'[,] Size_ _!_ . . q p <br /> Liquid Depth ---------- <br /> Capacity 14_41.0______ Typ ---- Material__ ---------- No. Compartments A-------_---- <br /> Distance to nearest: Well ____ o�_ __________________FOUndatlon _ �__� _________ Prop. Line ____.s '.:.,_____. <br /> LEACHING LINE jJ No. of Lines ____/----------------- Length of each line----- - Total Length !_t .�----------- <br /> 'D' Box 410—____- Type Filter Material 444f,--------Depth Filter Material _ __ <br /> ______ Foundation <br /> --------------------- <br /> Distance to nearest: Well ______� ____�` <br /> _ 'Q__ __ .......... Property Line. ___ ___...__.__._.__ <br /> SEEPAGE PIT fM Depth ._ �._.___ Diameter _ ____ Number 3 Rock Filled Yes No ] . <br /> p __" <br /> Water Table Depth ----I-�--------------------------------------Rock Size � A-I------------------- � <br /> Distance to nearest: Well -/± -----------------------------Foundation _/0_-`-__---_-___ Prop. Line _r----•----- <br /> REPAIR./ADDITION(Prev. Sanitation permit# -------------------------------------------- Date ----------------------------------) <br /> Septic Tank {Specify Requirements) --------------------------------------------------------------------------------------------------------- ---- ------ <br /> Disposal Field (Specify Requirements) ------------------------------------------------------------------------------------------------------------------------------------- <br /> - ---------------k-_--------- ---------- - _ �_. -- --------------------•--•--------- �€ <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 /> "1 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 become subject to Workman's Compensation laws of California." <br /> Signed ---- ' Gl -------------------------------------- Owner <br /> By ------------------------------------------------------------------------------------------------------- Title ------------------------------------------------------------------------ <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY _____ _ ____ ____ _ _ _ __ _._.__.____________. DATE <br /> BUILDING PERMIT ISSUED ----------------------------------------------------------------------------------------- ---------------DATE ------------------------------------- <br /> ADDITIONAL COMMENTS ------------------------------------------------------------------•--------------------------------------------------------------- ------ <br /> ------------------------------------- -------- -----------------------------------------------------------------=------------------•-----------------------------------------------------. <br /> ---------------------------------------- - ---- <br /> Final inspection by: -------------------------------Date � � * " <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT >� <br /> E. H. 9 1-'68 Rev. 5M <br />