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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> ........ ... .................... ..... Permit <br /> _ (Complete in Triplicate) <br /> .. <br /> ........ .........•-_..............•--......_._. <br /> il Date issued <br /> This Permit Expires i Year From Dote 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 <br /> I!' <br /> ._.� . .. �. <br /> Regulations: <br /> JOB ADDRESS/LOCATION 'o . .-......_ CENSUS TRACT .................,...- <br /> ` ........ <br /> --— <br /> Owner's Name j .Phone <br /> ... <br /> �I' � :.:City . -t :._....:..._...:_.._ <br /> Address .............. .....lO _ ._ _. .......... <br /> I <br /> Contractor's Name f__ �^ � .....::.License # ---..... Phone .............................. <br /> ... /I -- ..... <br /> Instollotion will serve: Residence 2TA'partment House[] Commercial :❑Troller Court 0. <br /> Motel ❑Other ...................... :::.:....:- <br /> Number of livin units:_.,.._ - .... Number of-.bedrooms _.._. ge Grinder ,___________ Lot Size -------..............................:...... <br /> 9 � 1, <br /> .. <br /> _ .Garbo <br /> Water Supply: Public System and name ---- ----.:...... ........ = �.............. -•---- ._._...Private <br /> i <br /> Character of soil to a depth of 3 feet: Sand 0 Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> i <br /> Hardpan Adobe ❑ Fill Material ............ If yes,type ------------------------•-•• �. <br /> ,M <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.I' <br /> eptic tank or see ge pit permitted if:public,sewer is available within 200 feet,) <br /> j <br /> PACKAGE TREATMENT [ ] i SEPTIC TANK i Sias: _f .� _�. _ ------:------- Liquid Depth -- .�.................. <br /> Capacity, &,k <br /> .0 Typ � '----- Material ....... No. Compartments ......... <br /> •... <br /> Distance to nearest: Well _.__..... � Foundation ..--�A__.•-_••----. Prop. Line <br /> ............ <br />' LEACHING LINE [V� No.! of Lines ......9---------------- Length of each line-... _�............. Total ,Length __/. �........--••---• <br /> !!! <br /> De tli Filter Material .__. ..............................:... <br /> 'D' Box ..__�_.::.. Type Filter Material ------$..�.*--:- p <br /> IM s ........... � � r <br /> Distance.to nearest: Well ........5.,p . Foundation ):A_.............. Property Line.........----......::. <br /> SEEPAGE PIT [y� Depth_ _: .5�_..:. Diameter -��---- Number _________ ______''.__..... Rock Filled Yes No Q <br /> I1, <br /> 1./gid a X.��. .... <br /> II. <br /> • Water Table Depth .................�p�:_.:.............Rock Size .-� �d•---•-_._ ®.. <br /> Distance to nearest: Well ----•-�---.i�.........................Foundation .:_..__._. Prop. Line ............. <br /> REPAIR/ADDITION(Prev. Sanitation Permit# .................................-............. Date ..........-......................... <br /> SepticTank.(Specify Requirements) ----------------•-- ----------------- -------------........................................................................_.. ---------- <br /> Disposal Field (Specify Requirements) ------------...............----------------------------------• ---------- ----------------------------- ---------- <br /> .................. <br /> . <br /> IT - . � -••••-- -----••----•-- ----------------------- <br /> --------------- ----------•...----..----_.__._... ------ <br /> ................................... ! ......................... <br /> ��. (Draw existing a di -. -. . <br /> ........................•..........._.. ------------------- --- -- -----------------•-----------•-•------------------ -------------------......_............. - <br /> -. .. g nd required addition on reverse side) <br /> I hereby certify that I have:�orepared 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. Horne owner or liitern <br /> sed agents signature certifiesf 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's4C,9mnsatioe laws of California. <br /> Signed I' : :::�_. ::. __:_Owner <br /> �I *..:.__t.. . Title ..: ..... ......... ...._:__..::...................... <br /> . <br /> By ........... ------------- •• F--..._. <br /> I (If other than owner) : <br /> �I. FOR DEPARTMENT USE ONLY <br /> A ............. <br /> APPLICATION ACCEPTED BY _. ...... <br /> . . ............... ....•-.......... DATE ..�._...- - '..... <br /> BUILDING PERMIT ISSUED .•!I:.................... .....................� DATE .........::_.............................. <br /> . <br /> ADDITIONALCOMMENTS .aP--._.:...............................................•-•-----•.-.._._....._._...------.......-_-......._.__..----....._.-------- -.........------......... <br /> SII ...._..-••••--•--.......--_::...................... .... <br /> -.. :...... �) ... --- -------------•--•••------- ---------------------- ------.--__--------........... <br /> ........:_.__.-- <br /> j Final Inspection by. ..,Er r ... ................... --•-•---•• ... ........ . ....... ....Date ... . e ._..__._..... <br /> ��..•�!': �'.4� <br /> 4 __-_•� SAN JOAQUIN„LOCAL' HEALTH DISTRICT T _ _ �....,.• _ �/�, <br /> VDD 72 3 �K <br /> F_ H.1-3 24 1-'68 Rev. 5M <br />