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FOO'OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> Permit No: <br /> ---'--- -------'---'-- ---- '----------- ____ ______ '�---�--�-�. <br /> (Complete in Triplicate) <br /> -------- - -------------- i Date Issued <br /> This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a per 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 /> —yam -------'--- -'-------- CENSUS TRACT ------ <br /> ••----- <br /> JOB ADDRESS/LOCATION _._ 3`�------/Gu- --- <br /> Owner's Name -----� Phone J7rr J <br /> Address _._ � (� "� �� --- -----. City <br /> Contractor's Name ---- <br /> ----------------- - - ----- <br /> License # - r- ----- Phone _ 6�--- Ld-�_--- <br /> Installation will-serve: ' Residencelp Apartment House❑ Commercial❑Trailer Court i❑ <br /> ' p Mote! ❑Other --------------------------------------•---- t � X 12-5 I <br /> Number of'living.units:- ('._____ Number of bedrooms ----------..Garbage ind r ______.__. LotSize <br /> --- <br /> = -- Private ❑ <br /> p ,m a ❑ ------- ---- -------------- <br /> soil to a depth of 3 feet: Sand' Silt Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam <br /> Water Supply: Public System an ,name _______________ _ _____ <br /> Hardpan E] Adobe Fill Material------------- If yes,type ---------------------------- <br /> (Plot plan, showing size of,.lot, location of system ins relation to wells, buildings, etc. must be placed on reverse side.) N <br /> wJ• - s � A <br /> NEW INSTALLATION: (No septic tank,or seepage pit permitted if public sewer is available within 200 feet,} <br /> r-.+,w.•; - �- rIjt_,_ - , .....�. Liquid Depth PACKAGE TREATMENT [ I SEPTIC TANK;[-] 'ik-4,' Size----------------------------------- ----- q p --- <br /> Ca acifi ' l TXP = ------------ Material---------------------- No. Compartments ---------------•------ <br /> Distance to nearest: Well ` -------------••Foundation ---------------------- Prop. Line ------------•------• - <br /> ----_. ___ Len th of each line--------- <br /> 'D' <br /> g <br /> LEACHING LINE [ ] No. of Lines/-,F,------ `�.nV } - --- Total Lent ____________________________ <br /> 'D' Box ___�'__ Type Filter Material --------------------Depth Filter:, Material -------_----------------------------•------- <br /> I <br /> Distance fio nearest: Well ________________________ Foundation _._-_____--------__---- Property Line _____--______----.-..--- <br /> De Depth _-' -- -=_--- -Di&ieter ------ Number --------------------------- Rock Filled Yes ❑ No ❑ y <br /> SEEPAGE PIT [ ] p , <br /> WateAable!Depth -------------------- ------.-------•------------Rock Size --- '--------------------------- <br /> r'� <br /> —" Distance 'to nearest: Well ---------------------•----- -•------••__Foundation ---------------•---- Prop. Line _. ----------.--.. <br /> REPAIR/ADDITION(Prev----Sanitation Permit=# -------------------------------------------- Date ___________-_^------------.-------1 <br /> i <br /> i Septic Tank {Specify Requirements ------------------- ----------------•-----------------`-:-`_ --------------- <br /> :- <br /> Disposal Field (Specify Requirements) ----_--- - --=�/ ----- <br /> ' ---- - <br /> -- <br /> -------- ' <br /> ---------- <br /> --------------------------- --------------- ------------------------------------- <br /> ------------------------ -------------------------------------------------------------------- <br /> '­(-Drofw-&'Xisiting 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 in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed ----------- w Y• Owners <br /> { <br /> By <br /> -------------- Tithe " i <br /> - <br /> ------------------------ -------- -------- <br /> (If othe an owner) <br /> i <br /> 15 FOR .DEPARTMENT USE ONLY <br /> i ---. DATE ---- ----��- --�----'--- ------ <br /> APPLICATION ACCEPTED BY _�` - vhf G�__✓__----------------------------------- <br /> BUILDING PERMIT ISSUED ---------------------------------- DATE - <br /> ADDITIONAL COMMENTS -------------------- <br /> ----------- -- ------------------------------------------ <br /> ---------------------------------------------------------------------- - - <br /> --------- <br /> --------------------------- ------ �- _ _. - <br /> ------- - - - - <br /> Date <br /> Fina! Inspection b i -----= -- - ------ ------------------------ <br /> p y: <br /> --- - - - ------ ---- - -- <br /> ------ ---- - --- - <br /> ' SAN-JO : UNOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />