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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ---------- -- --------------------------- ---------- Permit No. <br /> .. (Complete in Triplicate} <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 with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION .---- - _b__t__-------l�U.----4�< Y (�(� V__Od- '--------------- - ----- ---CENSUS TRACT --------------•-------- - <br /> Owner's Name ------ s1C Ci.r2_ ._ M ------------------------------------------ --------.-------------------Phone ._.. <br /> Address ------------- -- - . Qk#f4�"i.. ? t k <br /> -`�._ -----R!2--------- City -- <br /> Contractor's Name I O ---------------------------------------License # ----- ------------------ Phone ---------------------•-------- <br /> Installation will serve: Residence Apartment House❑ Commercial ❑Trailer Court <br /> Motel ❑Other -----------------------------------•----•--- <br /> Number of living units:_-.. Number of bedrooms ----r------Garbage Grinder .4..__.. Lot Size -----A________________________________ <br /> Water Supply: Public System and name ---------------------- --------------------------------------------- ---- •------------------------------------Private <br /> –' <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 /> W <br /> (Plot 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,] ` �p <br /> PACKAGE TREATMENT ] SEPTIC TANK J� <br /> [� Size--------- -- - -- - --- ---------------- Liquid Depth ----Z - <br /> Capacity .�___.__ Type __. ...��__-. Material4 --____ No. Compartments 2– <br /> Distance to nearest: Well --------- <br /> .-_-._/-5b a_______________Foundation .--I0.........__- Prop. Line .._�_-----_----. <br /> LEACHING LINE [ ] No. of Lines ------L---------------- Length of each line--------- Total Length ...-A-1r� _____----._- <br /> 'D' Box _-.�`�5.. Type Filter Material-_ C-_...Depth Filter Material --..-<-..---........................... <br /> Distance to nearest: Well ----- ------------- --- Foundation ------------------------ Property Line .-.._.._._._..-- ....... <br /> SEEPAGE PIT [ ] Depth ___---------------- Diameter ---------------- Number ---------------------_...--- Rock Filled Yes ❑ No ❑ <br /> Water Table Depth ------------------------------------------------Rock Size -------------------------- <br /> Distance to nearest: Well ----------------------_-.___.....___---Foundation -------------------- Prop. Line .__.-...._..._._.____. <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ---.-----_--------------------------------- Date ----------------------------------) <br /> Septic Tank (Specify Requirements) ----- -------------- ------------------- ------------------------------------------------------------------------ <br /> Disposal Field (Specify Requirements) ------------------------------•-------------------------------------------------------------- --------------------------------------- <br /> ---------------- --------------------------- -- --- ----------------------------------------------------------------------------------------------------------------------------------------•------------ N <br /> --------------- - - ------- __ <br /> - - - - ------------------------------------------ <br /> (Draw existing 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 agents signature certifies the following: <br /> "I certify that i the performance of the work for which this permit is issued, I shall not employ any person in such manner <br /> as to become bject tro�Woorkm�n's Compensation laws of California." <br /> Signed --- - w --��`'�'"-`-`--- Owner <br /> By ---------- - ------- ------------------------------------------- -- ---------------- Title ----------------- <br /> ---------------------------------------------------- <br /> (If other than owner) <br /> FOR DEPARTMENT 11SE ONLY <br /> APPLICATION ACCEPTED BY - - ----- ----- --- - - -------- DATE - I-1 --------------- <br /> BUiLDING PERMIT ISSUED ------ ---- ------ ---------------------------------------------------DATE - --------- ------------------------- <br /> ADDITIONAL COMMENTS <br /> --------------------------------------------------------------------------------------------------------------------------------------------------I------- --------------------------------------------- <br /> ----------------------------------------------------------------------------------------------------- <br /> -ADCT <br /> - <br /> ---------- ----------------------------------------------- <br /> --- <br /> --- --- <br /> ----------------------------------------------------------------------------------------------- <br /> Final Inspection b ----------------------------------------------- �"--- <br /> - --------- <br /> - ---- --- -- <br /> PY- - ----- --- --------- --�.r-! -�t�- -- ate ---- --=-�-d------- -------------------- <br /> SAN JOAQ IN LO L HEA <br /> E. H. 9 1-'68 Rev. 5M <br />