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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ------- -------------------------------------------------- I J Permit No. <br /> --° - -- - ,Complete in Triplicate) 'X <br /> __ This Permit Expires 1 Year From Date Issued Hate Issued <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 /> JOB ADDRESS/LOCATION ._ ]'1570.77 .r --- _-- C '}� -------------------------- <br /> _ 1. ---------CENSUS TRACT __________________________ <br /> Owner's Name ------ - ---------------------------Phone <br /> i -� , <br /> Address ------ ---------- City ----------- �1'l _ _ [ —----------------------------------- <br /> Contractor's Name { __-__.License # - - 1- - Phone _-.1�3__a-____ . <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑Trailer Court <br /> Motel ❑Other -------------------------------------------- �,� <br /> Number of living units:------r Number of bedrooms ___3__.__Garbage Grinder -----------I- Lot Size ________ - ......__.. <br /> Water Supply: Public System and name --------------------------------------------------------------------------------------------------------------Private J9: <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> iH ra dpan ❑ Adobe '❑ Fill Material ------------ If yes, type ___________________________ <br /> (Plot plan, showing size of lot, localof system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank ort seepage pit permitted if public sewer is available within 200 feet,) <br /> [ [ ' O �f 1f�-- Liquid Depth ------____-- <br /> PACKAGE TREATMENT SEPTIC TANK' Size___-_______Y___1_/_�__Y_____k__ ______________ <br /> Cap city .J 3 ------- Type _ -- Material__ No. Compartments -----�:_........ <br /> Distance to nearest: Well ----------- _________________Foundation .....I d____-----__ Prop. Line ____ `.........-- <br /> I , <br /> LEACHING LINE [ ] No. of Lines ___` ------------- Length of each line---_--g--&----- ------ Total Length --__- ./,6_0----__._.__ <br /> D' BoxType Filter Material 6--------Depth Filter Material ---_--_sJ j.............................. d <br /> Distance too nearest: Well ------5-D----------- Foundation --------I-a---------- Property Line -------15.............. --�1 <br /> SEEPAGE PIT ] Depth _.}r_ _.______ Diameter _ 'Sf I_S_ Number ----------'A--------------- I r <br /> Rock Filled Yes Y�Vr No ❑ A, <br /> 7 <br /> Water Table Depth ------------------------------------------------Rock Size -------------------------------- _ <br /> Distance to nearest: Well _______� ______________________Foundation -----A_—___.---- Prop. Line ___--__ <br /> REPAIR/ADDITION(Prev. Sanitation Permit+ ____________________________________________ Date ----------------------------------) <br /> Septic Tank (Specify Requirements) _'--------------------____ V, <br /> DisposalField (Specify Requirements) ---------------------------•-- -------------------------------------------- --------------- ----------------------------------------- <br /> • '�` <br /> -------------------------------------------------- - <br /> ------------------------------- ------------------------------ -------------------------------------------------------- <br /> -------------------------------------------- <br /> ------------------ ------- <br /> ? (Draw existing and required addition on reverse side) <br /> I hereby certify that I have-prepared this application and-:th4t 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 Wor"kman's Compensation laws of California." <br /> Signed ------------------- =' ---------------------------------------------- Owner <br /> ,d <br /> BY ---JV�AC'e'r j��^----I�� ------ ------ -Title -------------- --------------------------------------------------------- <br /> i (If other than owned <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY _ --------------------- ---------------------------------- -----------------. DATE __.___.___.___________-_ <br /> - - -------------- <br /> BUILDINGPERMIT ISSUED --------------------- ---------------------------------------------------------------------------- - ---DATE ------------------------------------------- <br /> ADDITIONALCOMMENTS --------------- ------------------------------------------------------- ------------ --------------------- ---------------------- ----------•---------------- <br /> ----------------------- ------------------------------------- -------- --- --------------- --- ---- --------------------------------------------- <br /> --------------------------------------------------------------------------------------------------------------------------- <br /> - ------------------------ -- <br /> Final Inspection b <br /> P Y: -------------------------------- -- - - --- -- ------------�-=---- -------------- - - - Date --1 - �7 - ------------------ <br /> SAN <br /> - - - •------- <br /> SAN JOAQUIN LOCAL HEALTH ISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />