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FOR OFFICE E: APPLICATION FOR SANITATION PERMIT <br /> 9 F <br /> (Complete in Triplicate) Permit No_ _____________________ <br /> ---- ---- --- --------- 7 -1---------------------------- This Permit Expires 1 Year From Date Issued Date Issued,/O_:"� ._ . <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 /> / � <br /> JOB ADDRESS/LOON -- -- - - ---- --- •- G�_G� -- ------------------ ------ CENSUS TRACT --•-----------•--------- <br /> Owner's Namet /�` _�� {�• / Phone " <br /> -------------- <br /> Address ---- JCity <br /> -AlContractor's Name ----- ---- ----- -- <br /> -le ------.License # :� - one%__ '" �� <br /> I Installation will serve: Residence Apartment House❑ Commercial :❑Trailer Court ;❑ <br /> I Motel ❑Other ------------------- <br /> Number of living units:------1.--- Number of bedrooms _.,-----Garbage Grinder•/ `D___ Lot SizeV <br /> kWater Supply: Public System and name ---------------------------------------------------------I------------------------------------ ---------------Private <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Gay ❑ .Peat ❑ -.Sandy Loam EJ..—Clay L.oam_Q___ <br /> Hardpan ❑ Adob*❑ Fill Material_._ If yes, type ____________________________ <br /> (Plot plan, showing size of lot, location of system in relation to- we)Is, 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 /> { ]_.. I ] '� `- - -------- -------- Liquid Depth <br /> PACKAGE TREATMENT'- SEPTIC TANK _V Size-_-_--- -__ <br /> Capacity ---- ----------- --- Type -------------------- Material---------------------- No. Compartments ------- .-----• "N <br /> Distance"to,nearest: Well _--________________________________Foundation ---------------------- Prop. Line ----._..__,_..________ <br /> ,4 <br /> ' LEACHING LINE [ ] No. of Lines ------------------- Length of each line---------------------------- Total Length ----------------............ <br /> 'D' Box ------------ Type Filter Material --------------------Depth Filter Material ----------------------------------........... +� <br /> <---- <br /> —Di stance-to-nearest z Well' ------------------------ Foundation ________________________ Property Line. _--_______________-:---. ,l <br /> SEEPAGE PIT:.'[ ] I Depth -------------------- Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No .0 <br /> Water Table Depth --------------------------------------------._Rock Size -------------------------------- <br /> t bistance to nearest. Well ----------------------------------------Foundation -------------------- Prop. Line ---------------------- <br /> REPAIR/ADDITION{Prey. Sanitation Permit# -------------------------------------------- Date ----------------------------------I <br /> Septic Tank (Specify Requirements) ---------------- -- ------ -- --- ------------ ------ --------------------------- <br /> j- e"o <br /> Disposal Field (Specif)f--Requirements} --------- ------------=- 1 - --------------- ----------------- <br /> ------ -- T� 1 ----- - ' <br /> (Draw existing and required addition on reverse side) <br /> l­hereGy: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 <br /> licen-sed agents signature certifies the following.14 <br /> ` "I certify that in the perfoimanCe of the work fbr which this permit is issued, 1,06h not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed --------------- s - Owner,' <br /> i <br /> By ----- --- --- ------------ - - 1 s ;------------------------------ Titler�l� -------------------- <br /> (If r'F}iaIn} ow ner) <br /> ' FOR DEPARTMENT USE ONLY <br /> M APPLICATION ACCEPTED B ------------------------- i DATE ----- ---- -------- <br /> BUILDING PERMIT ISSUED-"'_""'--- = -------------------------------- '-------------------------------------DATE <br /> ADDITIONALCOMMENTS ---------------------i-\-----------------------------------------•------------------------------------------------------------ ------------------------------- <br /> -----------I-------- ---------- --------------------------------------------- ----------------------------------=------------------------------------------------------------------------------- <br /> { t� ----- <br /> 6_. <br /> Final Inspection by: -------------------------------------------------- <br /> w ---------------------------------------------------------------------------Date -- -fir-- ---- - 4- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 4 <br /> E. H. 9 1-'68 Rev. 5M, <br />