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FOR OFFICE DSE: APPLICATION FOR SANITATION PERMIT <br /> - 0---7p All?v' Ate- ,,:o .. <br /> (Complete in Triplicate) Permit No. 76- __. <br /> This Permit Expires 1 Y"r From bate Issued Date Issued <br /> Application is hereby made to.the San Joaquin Local Health District for a per 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 .-- -6-6-------------- #t . ------------- ------ ---CENSUS TRACT -------------- ----------- <br /> `` k <br /> Owner's Name __ �_-h-). Tca/'1- rpE - --- ----- Phone <br /> Address -- ------ Cit <br /> ----------------------- Y - ��----------------------------------------------------------- <br /> ' , � License # - -�� <br /> Contractor shame - � --- -- -----T Phone <br /> Installation will serve: Residenceartment House-E] Commercial �❑Trailer Court ',❑ <br /> Motel ❑Other -------------------------------------------- <br /> Number of living units:___________ Number of bedrooms ___. _...Garb,qa-g-.e G i der Lot Size ___________---____________________________ <br /> Water Supply: Public System and name ------- __ ___ C �_C� __S !� - ______._ --___•_Private ❑ <br /> - --------------- <br /> Character of soil to a depth of 3 feet: Sand'❑ Sift Clay ❑ Peat❑ Sandy Loam •❑ Clay Loam :❑ l <br /> Hardpan ❑ Adobe-' `Fill Material _Z_VQ__ If yes,type ____________________________ <br /> (Plot plan, showing size of lot, location of system in /elation to wells, buildings, etc. must be placed on reverse side.) <br /> II NEW INSTALLATION: (No septic tank or seepage pit permitted if rpublic sewer is-dvailable within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] Size-------------------------------------'---.-_"___ Liquid Depth --------------------,-•--- �; <br /> Capacity ---- ----------- -- Type -------------------- Material------------ -------- No. Compartments ------ --------------- <br /> t � <br /> Distance to nearest: Well ------------------------------------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 /> Distance to nearest: Well ________________________ Foundation ------------------------ Property Line _.______.. ...... <br /> SEEPAGE PIT [ } Depth -------------------- Diameter ---------------- Number --------------------- ------ hock Filled Yes ❑ No <br /> d. Water Table Depth,--------------------------------------- --------Rock Size -------------------------------- <br /> r <br /> Distance to nearest: Well ----------------------------------------Foundation --------------------- Prop. Line ...._.__..______.___.. <br /> REPAIR/ADDITION(Prev. Sanitation Permit# --------------------------------------- ---- Date -------------------.---.---------_} <br /> Septic Tank (Specify Requirements) ------------------------- ----- -------- <br /> ------ ------------ <br /> q osal Fie1�l [Specify Requirem nts) `�1�a ------- -- - ---- T 1�_-e, .- -------- <br /> or. <br /> ------- <br /> ----- ---- ' `� ----------------- <br /> ------------------------------------------------------------- <br /> �Draxi`stling n equired addition on reverse side) <br /> I hereby certify that 1 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, 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 /> 1 <br /> BY " ----- - - - -- ------- '- -- --�'----------------------------- Title --------- ---------�--- <br /> iI o e -than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED DATE _ _-_ __-_-- -- -- -- <br /> BUILDING PERMIT ISSUED ---------------------- -DATE --------------------------------- <br /> ------------ ---- ----- ----------------------------------------------------------- <br /> ADDITIONAL COMMENTS ----------------------- <br /> f <br /> ----------------------------------------- ------ ------ -------------------- - --------------- --------------------- ---------- --------------- ---- <br /> ------------------------ <br /> --- <br /> -------- - --- ----- --- -- - �r <br /> � -- <br /> Final Inspection by: --- :--- - ------ -- -- ---- - ---------Dat ------- ------- <br /> t N JOAQUIN LOCAL HEALTH DISTRICT �i� ! z <br /> E. H. 9 1-'68 Rev. 5M <br />