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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT p ' <br /> ---------- ------------ Permit NoU—�0 ' <br /> (Complete in Triplicate) ----- <br /> _-- This Permit Expires 1 Year From Date Issued Date Issued '......-.N.� <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/LO .............._...-CENSUS TRACT .. - �.-----:----- <br /> �i <br /> / --- -- r <br /> Owner's Name i ------------------------------------ -- Phone ------------------------------------ <br /> I <br /> l <br /> Address city c[ c • r G-3 _ #_' city -- ' <br /> ------------------------------- <br /> Contractor's Name - ---- -K License #�� c Phane <br /> Installation will serve: Residence Apartment House❑ Commercial ❑Trailer Court l❑ <br /> j Motel ❑Other --------------------- ------- <br /> --------------- <br /> Number <br /> -----r -Number of living units;.....1----- Number of bedrooms xe4------Garbage`Grinder ------------ Lot Size ..............______--_----------/-.----_ <br /> Water Supply: Public System and name ------------------------------------ -------------------- ----------------------- -------------------------Private [7 <br /> R ' <br /> Character of soil to a depth of 3 feet: Sand'El <br /> it-t❑ Clay ❑ Peat ❑ Sandy Loam -E] Clay Loam E] ' <br /> Hardpan E] 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 IWALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> e <br /> V� <br /> PACKAGE TREATMENT [ ] SEPTIC TANK f ] Size------------------------------------------------ Liquid Depth -------------------------- ; <br /> Capacity - ------------------ Type -------------------- Material--- `- No. Compartments -----------------_---- <br /> Distance to nearest: Well ------------------------------------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 <br /> ---- .------------------Distance to nearest: Well -----------------------------------,----Foundation ----------°---N-... Prop. Line -------.---_--....-- <br /> R€PAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------._--------------) <br /> Septic Tank (Specify Requirements) -------------------' -------------------------------- ------------------------- <br /> - <br /> Disposal Field (Specify Re uir encs) ----.� -�--------- -- c---- o -- c - <br /> � � 3-3, r <br /> 1 b ----- --------- - -----'- ------ --------------------- <br /> --------- -- -------------------- <br /> - ------------------------------------------- <br /> (Draw exsing and required addition on reverse side) <br /> h <br /> E 1 hereby certify that 1 haveprelaredthIsapp1ication and that the work will be done-in accordance with San Joaquin <br /> C 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: 1 <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 /> k as to become sub' Workman's Compensation laws of California." <br /> Signed ------ -------- ---- -- ---- ---- ----------- ------------------_------- Owner w <br /> Title ' <br /> ot <br /> By ---- ---: - - - --------- r ---- -- ------------ ------------------------------------- <br /> f other than owner " } ' <br /> FOR .DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED-BY_ _. _._ <br /> ------------------------------------------------------------- --- --------------. DATE _'" - ----•I--------+-------- <br /> BUILDING PERMIT ISSUED ------------------------ ------------------------------------------------------------------=--------------DATE -- ----------•----------------------------- <br /> ADDITIONALCOMMENTS -----------------------------------------------------------------------------------I------------------------------------------------------------ <br /> ------------- --- -- -- ---------------- - ------------------------------------------------------------------------------------------------ ------------------------------------------ <br /> i --------------------------------------------------------------- -------------------------------------------------------------------------------------- --------------------------------- <br /> In - Z- -------------------------------------------------------------------------------------- <br /> Final Inspection by: ----.Date _- � '� --------------- <br /> I SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ] . H. 9 1-'68 Rev. 5M <br />