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iM <br /> FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> - ------------------ - <br /> (Complete in Triplicate) Permit No. <br /> y �------ - Date Issued - 3-- - - 16-u/ <br /> This Permit Expires 1 Year From bate Issued <br /> ---- - --------fes'-"=- --- -- - - <br /> 5' Application is hereby made to the San Joaquiii-L-ocal-Health�District-for a permit to construct and install the work herein <br /> described. This application is made in compliance with C unty Ordinance No. 549 and existing Rules and Regulations: <br /> Q� <br /> JOB ADDRESSfLOCATI !__7_ be- f1.�o----------------------------------------CENSUS TRACT -------------------_----- <br /> II � <br /> -` � <br /> ......-- -------------- - -------Owners Name ---------- ------------- <br /> JQ <br /> � h <br /> --------- ------ - - City ---- ............ <br /> ---- ----- <br /> Address iII '166- <br /> --------License # ------- Phone ------------- <br /> Contractor's Name - <br /> Installation fW <br /> will serve: Residence ❑ Apartment HouseXCommercial ❑Trailer Court i❑ <br /> Motel ❑ Other -------------------------------------------- <br /> I f � <br /> .Number�,of_living,units:-_._I-------Number umber -of -------- --- <br /> Water <br /> _Water Supply: Public System and'�name --------------------------- -------------------------------------- - -----Private <br /> Character of soil to a depth of 3 feet: Sand'❑ ❑Silt Clay E] Peat ElSandy Loam Clay Loam E] r <br /> ► Hardpan ❑ Adobe f-I Fill Material ------------ If yes, type ---------------------------- ■�J <br /> relation-to-wells-, ,buildings, etc. mus; be placed on reverse side.) <br /> (Plot plan, showing,size of lot, .location -of in relation o•wells, <br /> #NEW INSTALLATION: (No septic tank or seepage pit permitted if,publicy.sewer is available within 200 feet,] <br /> ' .� <br /> PACKAGE TREATMENT [ I SEPTIC TANK f ] Size----------------------*.------------------ ---- Liquid Depth --------------•------.----- <br /> CapacitY� -Type X Material-------- -= C <br /> ------ No. ompartments ---------------------- <br /> Distancei� to nearest: iWell ----------------- <br /> -------------------Foundation------- -----_ Prop. Line --------- ------------ <br /> LEACHING LINE [ ]► No. of Lines _._____.___ _!__________ Length of each line-___ !___________ __ Total Length ;------------.--------------- <br /> l D�•Box I�----------- Type,Filter Material --------------------Depth Filter Material ---------------------------------- <br /> t <br /> i«. ti � Distancelto nearest: Well—------Foundation -_�--;.____------ Property Line -------- --------------- <br /> Rock[ ] Depth '_________________ Diameter ---------------- Number ----__.._______�---------- Rock Filled Yes ❑ Na <br /> J I <br /> E y,. Water Table Depth =--------------------- Rock Size ' "`' <br /> .�. . �`" ' '= ' ._.Foundation •--------- <br /> Distance to nearest: Well _________________ _ _ _ r � <br /> ;REPAIR/ADDITION(Prev. Sanitation.Permit.#- -----.----------------------------------- Date -------------------:----------.---� <br /> 1 Septic Tank (Specify Requirements) -------------- ------- --------- ------------------------------------------ ----------------- --------------------------------------- <br /> Disposal Field (Specify Requirements) ------ ---- -�------ "``�` �3 - __ .. <br /> -� ...� <br /> -. <br /> ----`- ----- .r <br /> ------- N------------------------- <br /> I <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------=------- <br /> ----------------------------------------------- <br /> a (Draw existing and-required addition on'reverse side) <br /> 1 hereby certify thatI have prepared this application and that the work will be done 'in accordance with San Joaquin <br /> County Ordinances, State Laws,i�and Rules and Regulations of the San Joaquin Local Health District. Home owner or licen-- <br /> sed agents signature certifies the-following: y,r.•�"'" �""' --• ._ <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 /> gas to become subject to Workman's Compensation laws of California." <br /> Signed ---------------------- I. ---- Owner .iRw t `- <br /> BY ----------- -c I� ----------------- <br /> ------- �-------------- Title <br /> `----------------------------- - <br /> (If oth t n owner) <br /> ' II FOR1. <br /> USE ONLY <br /> APPLICATION ACCEPTED BY __ ---____ __ _-_ —" <br /> ` "-..r,a. -- -----. DATE ---- ----------- ------------------- <br /> BUILDINGPERMIT ISSUED .-------�i---------------------------------------------------------------------------------=----- ----:---DATE --- ------------- -------------------- --- <br /> 'ADDITIONAL COMMENTS ---------I]--------------------------------------------------------------------------------------------=------------- ------ -- <br /> ---------------------------------------------------- <br /> . . <br /> i' <br /> ------- -------------------------------------------------------- -- ---- <br /> ---------------------------------------------- -------------------------------------------------------- <br /> <_ I -- <br /> .Final Inspection b -------- --=------------------------------------- --------- e-. a -. ------ --------- <br /> i <br /> SAN JOAQUIN;LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M i <br />