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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT a <br /> = � letehcate} Permit <br /> (Compn Tri p <br /> ---------------------- '--`-- -- �5 = <br /> ______________ This Permit Expires 1 Year From Date Issued 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/LOCATIO ,,--/ ----------------------CENSUS TRACT __• ----------_------ <br /> Owner's Name ----- ` r /� r 1r ---------------------- <br /> - Phone <br /> Address - ----------------- = sa --- -- lC/-/ C L Z--- City <br /> r ^' <br /> Contrac#or's Name l-_ ------Qojw -6/ <br /> ------ #`� «� a._ Phone �fJa o%� <br /> Installation will serve: Residence Apartment House�❑ Commercial ❑Trailer Court ;❑ <br /> Motel ❑ Other <br /> Number of living units:-----_--_ Number of bedrooms -_.___Garbage Grinder —/'W' _ Lot Size <br /> Water Supply: Public System and name ----------- <br /> -------------- ------•.._ - --------------------_-------- ---- Priva e [�/' } <br /> ------------------------------- - _ <br /> Character of soil to a depth of 3 feet: Sand'El Silt ElClay .❑ Peat❑ Sandy Loam ❑ 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.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ SEPTIC TANK [ ] Size--------------=--------------------------------- Liquid Depth -------------------------- <br /> Iv <br /> I <br /> Capacity -------------------- Type -------------------- Material--------- ------------ No. Compartments ------------------•-- <br /> est Well <br /> --=------------------ -- -- dation --------------------- Prop. Line ---------------------- <br /> -LEACHING LINE, [ ] No. of"1-ines Length of each line-_______' <br /> Distance to nearest: WellFoun <br /> - -------- ------ Total Length ------------------------- <br /> 'D' <br /> ------------- --•-------'D' Box ------_V____'Type Filter Material --------------------Depth Filter Material -------------------------------------------- <br /> f . Distance to nearest: Well ---------------- Foundation __-____ ---------- .Property Line ---------.________-____. `Nt <br /> SEEPAGE PIT [ j Depfh ---------i____------ Diameter ---------------y Number ----------------_------__ <br /> ___ Rack Filled Yes �..- •No ij] <br /> .. r y �•, <br /> Water Table Depth -----I---------------------------------------� Rock <br /> I Size --------------------- - l •-a <br /> ' <br /> Distance to nearest: Well ---------------------------------------Foundation -------------------- Prop. Line`_..................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ____________________________________________ Date --__--______-_____________________) ' <br /> Septic Tank (Specify Requirements)#° '` --- ----- <br /> Disposal Field (Specify Requirements) _______:- } .� <br /> --------------------- <br /> _ <br /> ----------- ----- <br /> ---------------------- <br /> ---------------___--------------_-----__ <br /> ---- -------------------- ------------------------------------------------------%--i-------------------------------------------------------------- <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with'San Joaquin <br /> County Ordinances, State Laws, andtRules and Regulations of the San Joaquin Local Health District. Home owner or licen- <br /> sed agents signature certifies the following: <br /> "1 certify that in the performance of #he'iivork for which this permit is issued, I shall not employ any person in-such manner <br /> as to become subject rkman's-C6mpensation laws of California." <br /> Signed -- ---------------------- ------ - - ---- Owner ' <br /> - ------------------- - ---- <br /> - -- ----------- - <br /> - --------- <br /> � ll <br /> BY --s----- - - -------- ------------- Title ------- <br /> P 7 <br /> _______________ <br /> ot a owner) -------- <br /> P RTMENT USE ONLY / <br /> APPLICATION ACCEPTED BY = -------------------------- <br /> ----------------- DATE b s' <br /> BUILDING -----------------PERMIT ISSUED ------------- - -------- '-----.._.DATE ------------------------------- <br /> ADDITIONAL COMMENTS <br /> ------ = -----�l.'�"--- V_ �C az�= ' - ----------------- <br /> ----------------------------------------- ---- -------------------------------------------------------------------------- ------------------------------ -----�--------------= -----= <br /> Final Inspection by: ------ - - - --------------------- ------ ---- -------Date __./1-✓ -------; <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1 '6$ Rev. 5M , <br />