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FOR OFFICE USE: APPLICATION', FOR SANITATION PERMIT <br /> ------------------------------------ ., Permit No,. _T��-------- f <br /> (Complete in Triplicate) <br /> ------ --- ----------------------------------------- <br /> ---------------------------------------------------------- This permit Expires i Year From Date Issued 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 wit County,Olddl' No. 549 and existing Rules and Regulations: <br /> @ssIf <br /> CGr'' sr.�rgs <br /> JOB ADDRESS/LOCATION _ --~ � ` -y CENSUS TRACT <br /> Owner's Name s1 � �-------------------------- -------------------Phone 7---A <br /> Address ----------------------X19-2------ •------- City <br /> Contractor's Name __-_-- ^1--, 1 -/- }{---54 ------------------License #�� —f-f-4-- Phone <br /> Installation will serve: Residence J0 Apartment House❑ Commercial ❑Trailer Court ;❑ <br /> Motel.0 Other--=------------------------------------------- <br /> Number <br /> =---------- ----------------- -- -Number of living units:_-_ .... Number of bedrooms -�r-=.--Garbage Grinder .----------- Lot Size LUQ -jf -------------------- - <br /> Water Supply: Public System and name ----------------------------------------------------------------------- f------------------------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand jW Silt❑ Clay ❑ Peat❑ , Sandy Loam ❑ Clay Loam.l] <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.) G <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ I SEPTIC TANK'74 ____ ______ liquid Depth __� ___------..------- <br /> t <br /> Capacity ------- Type/l ,-� �Material__G_ No. Compartments -A---------------- <br /> RedDistance to nearest: Well ------------------------------------Faundation ---------------------- Prop. Line -------------- <br /> LEACHING <br /> --------- --LEACHING LINE [ ] No. of Lines—/Z-Xrl---- Length of each Tline----__---------------------------- Total LengCt�h ............. <br /> ,�,.1�-�-- ,._ <br /> 'D' ,Bo - <br /> % x —/ Type,Filter Material -_ �$---Depth Filter Material ----- ---/--------------------------------- <br /> Distance to nearest: Well ------------------------ Foundation ----40----------- Property Line. J-4 <br /> SEEPAGE PIT [ ] Depth ________________ ___ Diameter ---------------- Number ------ --------------------- Rock Filled Yes ❑ No 0 <br /> WaterTable Depth ------------------------------------------------Rock Size -------------------------------- <br /> Distance to <br /> ------------------------------- <br /> Distanceto nearest: Well -------------------- ,-.------------Foundation ---------------.---- Prop. Line ---------------------- <br /> { <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ------------------------------------ ---.----,Date -------------------------•--------I <br /> Septic Tank (Specify Requirergents)�------- ----------------------------------------------i=--w=- ------ ------ , --------------------------- ' <br /> Disposal Field (Specify Requirements),. ---------------------------------- -------------------__-_---- ------------------------------------------------------•--------------- <br /> i ----------------------- ----------------------------------------- �------------- ----- <br /> f <br /> k -------------{Draw e <br /> ------- ----- <br /> - ------------ <br /> -' ' isting 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 San Joaquin <br />' County Ordinances, State Laws, 'and Rules—and Regulations of-the San Joaquin.Local Health District. Home owner or licen- <br /> sed sed agents signature certifies the following: - ----9.•b�. w.� _ , _ ," <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 /> �^- <br /> E Signed r IT i_ -----�:.�0�'Y------------------- Owner <br /> .. - Title �o, i�C O ----------------------------------- <br /> 6r <br /> - <br /> BY ------------- -- - ----- --- --------------------------=------------------------- ' <br /> (If other than ner) <br /> FOR .DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY --------------- ---- �----.----_-__--------_ --_ _ <br /> - - - ----------------------------------. DATE -------- --�---�--"��_-�_ <br /> BUILDING PERMIT ISSUED --------------------------------=`"- ----- --------DATE ------------------------------------------- <br /> ADDITIONALCOMMENTS --------------------------------------------------------------------------------------------------------------------------------------------------- ---------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> -----------------------------------------------=---------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> --------------------------------------------------- -- --- - <br /> ----- <br /> Final Inspection by -------- -----------.Date __-- -- " �--------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'b8 Rev. 5M <br />