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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ----------------------------------------------------- -- Permit No. <br /> (Compete in Triplicate) <br /> -------------------------------------------- ------ <br /> ______________-_._.__-__-___.___________-_______.__ This Permit Expires ] Year From Date Issued <br /> Date Issued ,S/,/��/___. <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/LOCATION S -------- \ --,q------------------------------------------------------------CENSUS TRACT --�OZ------------------ <br /> Owner's Namepkv1_---IRc-'-e -- -------------------------------- -------------------Phone <br /> Address - mom----------------- city ------ ------------------------------------------- <br /> Contractor's Name -- --------- ------.License # ------------------------ Phone ------------------------- -_ <br /> Installation will serve: Residence P<Apartment House❑ Commercial ❑Trailer Court ',❑ <br /> Motel ❑ Other_ 5- --- ----------------------------- j _ > <br /> Number of living units:------ Number of bedrooms _______Garbage Grind �.1 <br /> er t_._ Lot Size ___ _rI-�____IS0--------_------- <br /> Water Supply: Public System and name -------------------------------------------------------------------------------------------------------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam EJ <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 [ SEPTIC TANK I ] Size------------------------------------------------ Liquid Depth -------------------------- <br /> Capacity -------------------- Type -------------------- Material---------- - --------- No. Compartments ------•------ <br /> Distance to nearest: Well _____________-_---_______________Foundation ---------------------- Prop. Line --__-- _.-- .......... 67% <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 to nearest: Well _______________________________________Foundation ------------- ------- Prop. Line ___:_____.______._ <br /> REPAIR. ADDITION(Prev. Sanitation Permit# ---____ -___------___________________________ Date _-____--_`_------..-_--------____I <br /> ptic Tank (Specify Requirements) - _` __Q111 _ ttia-_ C-------------------------.---..-,------------------------.- <br /> Disposal Field (Specify Requirements) ------------i- -----rf---------- -- -------- <br /> ------------------------------------- -- - ------�--- 9 - ----- 1a - L'_ ' �C`' � t '� � Se �.�-----t�� <br /> - --------------------------------------- ----------------------------- - --------- ----------------------------------------------------- --------------------------------------- <br /> (Draw existing 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, I shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed'v '+J---)fin ------------- Owner <br /> By ------------------------------------------- ---------------------------------------------------------- Title ------------------------------- <br /> ---------------------------------------- <br /> w (if other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BYA -------------------------------------------- <br /> -----------------------------------. DATE ---- . ----------------- <br /> BUILDINGPERMIT ISSUED -- - ------------ ----------------------------------------- ------------------------------------------- <br /> ----- - - <br /> ADDIONAL,CQ M NFa <br /> __ ------------------ ----------------------------------- <br /> -- -------------------- ---------- ----- <br /> - -- n------�I,u� - --- 41--------------------------- <br /> ----------------------- ---- ------------------------------- <br /> ----------07.1 <br /> Final fns ection b ------------------------- ___._Date 5__ _-__. <br /> SAN JOAQUIN LOCAL-HEALTH DISTRICT <br /> E. H. 9 1-'66 Rev. 5M <br /> .� <br />