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FOR OFFICE USE: 0 <br /> l),'o APPLICATION FOR SANITATION PERMIT <br /> --------------------------------------- Permit No. ---------------------- <br /> --------- <br /> -------------------- . <br /> ---------- - - <br /> {Complete in Triplicate) <br /> This Permit Expires 1 Year From Date Issued <br /> Date Issued~ _`P---- <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 ADDRESSAOCATION /'.5 J • ,+ Q-(/. u�------- --------- - --- - CENSUS TRACT -------------------------- <br /> �+ <br /> Owner's Name .-Z:9!�'----- ------- - ------------------------------------------------------- ----- -----...Phone ----------------------------- <br /> Address 1 Jr7 ' l �"� -` {` CitY j <br /> Contractor's Name a-j ------.License # I �� 37 _ Phone --------------•--------------- <br /> - <br /> Installation will serve. Resident [Apartment House❑ Commercial ❑Trailer Court ;❑ <br /> Motel ❑'Other ---------- -------------------------------- e <br /> =- <br /> Number of living units:------j---- Number of bedrooms --- ----Garbage Grinder -----._---. Lot Size ... - -« �--------- <br /> Water Supply: Public System and name ------------------------------------------------------------------------ ------------- -----------Private <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam Clay Loam ❑ , <br /> Hardpan ❑ Adobe ❑ Fill Material ------------ If yes, type ---------------------------- ! <br /> (Piot 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 /> PACKAGE TREATMENT [ ] SEPTIC TANK+[ ] Size-------------------------------------------------- Liquid Depth ----------------.---------- 0 <br /> Capacity ---- Type -------------------- Material------- -------------- No. Compartments ------ •------- <br /> f Distance to nearestTWell- -------------------------------------.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 ---.------------------------- Rock Filled Yes ❑ No i❑ <br /> Water Table Depth ------------------------------------------------Rock Size -------------------- <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ---------------------- -5 <br /> REPAIR./ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------_-_---} (5' <br /> Vr <br /> Septic Tank (Specify Requirements[ _. `. '----------------------------------------------------------------------------- ------------------<---------------------------- <br /> Disposal Field (Specify.Requirements) ---------- -------------------------------- --------------------------------------------------- -------------------- <br /> -------------I--------------- - ------------ ------(_ - � <br /> `- - ------------- <br /> V v <br /> hereby <br /> certify that I have prepared this a existing Cation and required <br /> add e . <br /> ------------- --------- ------ <br /> dition on reverse side) i <br /> y p p pp a work will be done in accordance with Sari 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, I shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> a <br /> Signed - -------------------------------------------------- - Owner <br />` BY -------- ---- -- ---- - <br /> Title _ <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ------------------------------------------------- ---------- DATE -. � _ 7% <br /> - - - - -•---------------- <br /> --- <br /> BUILDING PERMIT ISSUED ------------------------ ------------------------------- --------------------DATE --------------------------------- ----- I <br /> ADDITIONALCOMMENTS --------------------- --- ---------------------------------------------------------- --------------------------------------------------------- - --------- <br />' ----------- ----- ------------- ------ --------------------------------- - ----------------- <br /> ------------ <br /> ------------------- --------- ------- --- -------------- <br /> - -------- --------------- ----------------------------------------------------- Date-------------------------------------------------------------------------------------------------------- -------- <br /> Final Ins ection b ..-Y-`� � <br /> - ------_------ - <br /> p y <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> k E. H. 9 1-'68 Rev. 5M <br />