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b_ . - e. <br /> FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit Non_ l�_ <br /> 1" _ ___ <br /> ----------------------------------- 1 <br /> -----------------------------------------.---------------- This Permit Expires 1 Year From Date Issued <br /> Date Issued l�_ -----"?_3 ; <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 /> pL <br /> JOB ADDRESS/LOCATION . 0 -L- ------------------------- CENSUS TRAC <br /> -- ----------- <br /> --------------- <br /> -- ----- --- _ <br /> Owner's Name h !1--------� /V----------------------- - ----------- -------Phone __._�_ _0 <br /> Address - s� v�-• �- Qt7 ---------------------------------- City : /4,C 1c}------------- -------------- - <br /> *��. <br /> Contractor's Name -0.__ ___.ON_420�7l4____________________________________-License Phone <br /> Installation will serve: Residence ®Apartment House❑ Commercial❑Trailer Court '❑ <br /> Motel ❑Other --------------------------------------------wwgg <br /> Number of living units:-_ ------ Number of bedrooms .�5r___.Garbage Grinder ------------ Lot Size - ___�------`'✓`-'�._______________ <br /> Water Supply: Public System and name --------------------------------------------------------------------------------------------------------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand'EJ Silt❑ Gay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <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.) <br /> NEW INSTALLATION: {No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT { ] SEPTICtTANK f I Size------------------------------------------------ Liquid Depth --------------------------- I <br /> Capacity --------------�'—Type -------------------- Material- ------ No. Compartments ------ ------_------ <br /> Distance to nearest: Well _Z <br /> ___________ __________Foundation _.-_____.__________-_ Prop. Line ..................... 41T, <br /> LEACHING LINE [ ] No. of Lines __.____________________ h of ch line.____.__.--____ _____...--__ Total Length -----------_-------.-------- [V <br /> 'D' Box ------------ Type Filter l -- -----------------Depth alter Material ----- ------------------------------------ <br /> M <br /> to nearest: Well ___ ___ ______ Foundation _ ______________________ Property Line ------------------------ <br /> L <br /> _______________._._.___ rn E <br /> SEEPAGE PIT [ ] Depth _.__-.____._________ Diamet ___________ Number __ _________.____________ Rock Filled Yes ❑ NoWater Table Depth ------------- --------------- ---•._.. ck Size -------------------------------- <br /> Distance to nearest: Well ----- ----------------------- oundation --------------------- Prop. Line ------------------•.-- <br /> REPAIR/ADDITION{Prev. Sanitation Permit# ______________ <br /> Date } N <br /> Septic Tank (Specify Requirements) -------- ------------------------------ --- -- --- ---------- --------------- ----------------- ----•---- a <br /> Disposal Field (Specify Requirements} _____ Q- __._.._. _ _____, __ <br /> 3 <br /> 21?-� t5/t��2- <br /> --------------ng and <br /> ------ ------------------------------------------------------------------ <br /> ----------------------------------------------------------- <br /> hereby cert( that I have prepared this cation and required <br /> ad <br /> -------- - ---- ---- - ----------- ---- --- ------------ ---- ------------------------------------------------------------------------------------------------------------------------------ <br /> iDraw on reverse side} � <br /> y fy p p pp a 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, I shall not employ any person in such manner <br /> as to become subject to Workman's ompensation laws of California." <br /> Signed A Owner <br /> BY ------- -- <br /> Title ------- --- ---- <br /> -- ---- ---- - ---------- <br /> - - ----------------------------------------------- <br /> ,If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY _-__ _.___ _ ___ DATE ----- -------------- <br /> _ ___ ___________- <br /> BUILDING PERMIT ISSUED -------- ------------------------------ --------------------- --- <br /> ---------- ---------- --------------DATE -------------•------ ------------------- <br /> -- <br /> ADDITIONAL COMMENTS ------------------ -------------------- ---------------------------- <br /> ---------------------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> -------------------------------------- -------------------------------------------------------------- ---------------------------------------------------------------------------------------------------- <br /> ------------------------------------------------ <br /> = ------------------ ------------------ -----------------------------Date ---- <br /> Final Inspection by: SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> - G 4 <br /> E. H. 9 1-'b8 Rev. 5M <br />