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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT u <br /> �- --------- - Permit No. _�-j--------�� <br /> f � �"""""" ----- ., {Complete in Triplicate) <br /> 1 <br /> ---'-----"--__'_-------- --- '� _ - <br /> Date Issued._J= ~- <br /> This <br /> -------------------- <br /> Permit Expires 1 Year From Date Issued T <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 C unty OrA]rjanceZ:�,ncaexisting Rules and Regulations: <br /> 4__ --CENSUS TRACT -------------------------- <br /> JOB ADDRESS/LOC N ----- -------------- - ------ <br /> Owner's Name --- <br /> -------Phone._t-7=•��--- <br /> Address /- (,� = ---------------•-.. City. --------- / <br /> _ ----- -- ---- <br /> Contractor's Name -------- ----------- ------------------- --- - ----- -- --- - <br /> License # Phone ---= ---------- <br /> Contractor's <br /> ---- <br /> Installation will serve: ResidenceXAparti-neM House❑ Commercial ❑Trailer Court,"❑ <br /> • Motel ElOtFi6'r:---------------------- <br /> k <br /> Number of living units:---I------ Number of bedroo s+ ---3___Garbage Grinder ________._" Lot Size______ ______ _ ...___.. <br /> Water Supply: Public System and-name-=--=-=-------=--------- ---- --•-----•---------------------------• ------ I'[ivateX <br /> 1 `i4 <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ y Q Peat E] Sandy Loam ❑ Clay Loam [I <br /> ] • <br /> Hardpan ❑ Adobe❑41i Fill Material ------------ If yes, type ---------------------------- y <br /> (Plot plan, showing size ofTllot, location of system in relbtion"to wells buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No,septic tank or seepage pit permitted if public sewer is avilable within 200 feet,) ; <br /> 3 <br /> PACKAGE TREATMENT 1 <br /> SEPTIC TANK I s� Size---------------- <br /> ------ ------- --------- ---_ Liquid Depth --------------- <br /> ------ -� <br /> ------ <br /> Compartmentsi No.Ca <br /> Capacity -- ----------------- Type ------ ------------ Materit ------------ ------- Prop. line_.__ --_--•.----- <br /> {; <br /> Distance to nearest: Well _____ _- L-FoundationI 4 <br /> Len th of each lie___ -------------- -------- Tgtal Length --- - -------- °-- <br /> LEACHING LINE [ ] No. of Lines ______ -_ ! <br /> g <br /> Box ___-_.______ Type Filter Material _______ ---------L.DeDth Filter�Material --------------------------------{------ <br /> 'D' - I <br /> i— <br /> on -------------------- ro er- Line---- ------- i <br /> !v1 i <br /> Distance to nearest: <br /> we <br /> -"-"---- - "'�oundati -----1 P � <br /> SEEPAGE PIT [ ] Depth Diameter- ---------------- Nu-rp ler.----------------1----------'Rock Filled Yes ❑ No !❑ <br /> 1 tt � 1-f--R&&-Size <br /> 5. . <br /> water Tab.le,De th ---= --------- ---------------------------.�,t--M1R&k-Size ----1---------!---------------- <br /> i `` �------- Prop. Line -----------•----•----- <br /> Distance t3,neareSt:.Well ------f_---------- ..-------�-foundation 1 ----•---- P <br /> }.. ' <br /> Date -------------------- ------------) <br /> REPAIR/ADDITION{Prey. Sanitation PerTit# ________ --------________ v <br /> 1 r (j rte " I _ -------- <br /> -- <br /> --- <br /> i-._,.. _ _ - _ ._____ <br /> _ ____".__ _ ___ y_____ <br /> - ..,,,,,.,_Septic Tank (Specify Requirements)i--, f --------'-------- " E <br /> ,..�--'^ -----�__Q_s__" ------------- <br /> Disposal Field (Specify Requirements) _ _____ <br /> r r- ------------- <br /> ----------- <br /> i ' --------fy........ ----------- <br /> --------------------------- ---------------- g• <br />� _ } ►� t (brave existan and-required-add;ition_on..reversensid'e} � �# <br /> :4 �: a <br /> �r.. ," . 0 <br /> 4�1;M1hereby certify that I have prepared this application and that the work will be dame in accordance wH �San Joaquin <br /> county Ordinances, State Laws, and Rules,,anc!3"' ulations of the ;Sari Joaquin Local Health District. Home owner or licen- <br /> se�l;:agents signature certifiestthe following: r" r <br /> 4. <br /> k.: <br /> "I certify that in the performance of the work for which this ppeer.-mit kis issued, II shal employ any person in such in <br /> as to hecome subject 4o Workman -California." <br /> 's Compensation laws of-California. 1 <br /> C.'r " <br /> Signed _ I Own <br /> t } --------------------------------- <br /> -------- -Title ------ '-- �� <br /> Y --------- t S-- <br /> o nor) ,,,...--�-'---"�•'"",.� <br /> {Ifsother>tha <br /> { , /FOR DEFARTMENT USE ONLY ' <br /> i <br /> APPLICATION ACCEPT BY 1 ------------------------�s - DATE _.. 1 <br /> BUILDING PERMIT ISSUED J--------------------- ------f-------- -------------------- <br /> -'4---------------'. -, DATE ------- ----••---------- ----- ------------ <br /> I ADDITIONAL COMMENTS ---I--------/----------------- --------------------------- <br /> k _ � J "---------�---- ° '------------------- ------------------------------- --------- <br /> .. ------------------------- -- -------_- -F-- ---------------- ----------- ---------------- -------------------------------------------------k ------------------------- - . <br /> i ------------------------------------ --_ - - ----------- <br /> ------------------------------------- ---------- <br /> - at l <br /> Final Inspection by: - - �_- t .-. :. :: #.D e �- <br /> ' SAN JOAQUI,N LOCAL HEALTH. DISTRICT <br /> s C� 1 ` <br /> E. H. 9 1-'68 Rev. 5M <br />