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FOR OFFICE USE: A <br /> APPLICATION FOR SANITATION PERMIT -1 <br /> ------------------ <br /> (Complete in Triplicate) Permit No: <br /> --------------------------------------------------------- <br /> ---------------------- <br /> --------------_____________________ -------------------------------- _ This Permit Expires 1 Year From Date Issued <br /> Date 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 ADDRESS/LOCATION ��JI------------- t✓� +- , __-- V----------------- <br /> x`C'_ - --------------- --CENSUS TRACT -------------------------- <br /> ;�r- <br /> Owner's Name Phone // //! y <br /> Address -------------------E J-4---D_3-------- D._1/--' t`r`� ��------------. City t n----------•--------------------•----•---------••- <br /> Contractor's Name __1.0._��{-0.-r- _5----------------------------------------------License # Phone <br /> ! ----�D_ -•-- <br /> Installation will serve: Residence] Apartment House❑ Commercial❑Trailer Court 10 <br /> Motel ❑ Other -------------------------------------------- <br /> Number of living units:----/-___-__ Number of bedrooms --- -----Garbage Grinder ----- Lot Size ----- ------ <br /> Water Supply: Public System and,name ----------------------•------------------------------------------•-•-------- -------------••-------- ---------Private Q <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam jK 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.) Q <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 <br /> -----------------•---Distance`to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ...................... <br /> LEACHING LINE TA No. of Lines ------------ Length of each line_____ _ _.- g <br /> -_-_ Total Length . ________________ <br /> 'D' Box -----/----- Type Filter Material ---i--- .........Depth Filter Material __---._--l_9 f-�__-_____ <br /> Distance to nearest:'Well -----,�d_0------ Foundation ____-.a _�_____ Property Line ---�0--------- <br /> SEEPAGE <br /> �,j E <br /> p�J �f ____ Rock Filled Yes 21 No i❑ <br /> c�,.�--- Number -----=---- ---------- <br /> SEEPAGE PIT Water Table Diameter __ <br /> Depth ---------------�_r_----- - ----------------Rock Size ----------- ------ <br /> f <br /> Distance to nearest: Well - --/�4---------•-----------Foundation _.___ Q_______ Prop. Line _f. ........ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# --2----------------------------------------- Date ------ ----------- <br /> ---------------- <br /> Septic Tank {Specify Requirements) ----- -------------- - - -- <br /> ' r <br /> Disposal Field {Specify Requirements) f t�� c <br /> ----------------------------------------=--------------------------------------------------------------------------------- ) <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: r <br /> "€ 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 ---------------------------------- Owner <br /> O <br /> BY -�-���J ------------- -Title.------- s � ------------------------- <br /> ­(If other than owner) <br /> F DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY --- ------ --- - -- -- ---- ------------------------------------------------------------ DATE ---- J -------------- <br /> BUILDING PERMIT ISSUED ____ . _ .____ ---------- ---DATE ----------------------- <br /> ADITIONAL COMMENT - - ---- - - - ---------- -_---------------------------------- --------------------------------------- --------------------------- <br /> � r---------- ---- - -------------------------------- <br /> - ----------------------------------------- - <br /> -- ----- ---------- ----------------------------------------------------------------------- ----------- _-- -- --- <br /> Final Inspection by: --------- --- -- -- --- �`` Date -- = <br /> JOAQUIN LOCAL HEALTH DISTRICT <br /> _ E. H. 9 1-'68 Rev. 5M _ 11 <br />