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FOR OFFICE USE: —"APPLICATION FOR SANITATION PERMIT / <br /> 'f '- G' Permit No. <br /> / (Complete in Triplicate) <br /> 9F--- <br /> - - fib_ b 9 <br /> ----- C'---��--!'--�---� Date Issued <br /> .. .��-�•--�/ <br /> �I ►'` ` �- This Permit Expires 1 Year From Date Issued <br /> Application �s hereby mad <br /> 0 <br /> A <br /> pp y ��a to the San Joaquin Local Health District for a permit to construct and install the work herein <br /> described. This applicatiofcr is made in compliance with County Ordinance No. 549 and existi g Rules a d Regulati ns: <br /> JOB ADDRESS/LOCATI CENSUS T ACT ----- ---- <br /> ----- ---- <br /> Owner's Name F.- ------ --------- > ----------------- •----•--------- ----- --------------------- Phone 7y • - <br /> ' Address - - City -------------------=-------------•----------------------------------- <br /> ti <br /> Contractor's Name __.' ------ - - �------------------- ------------ ----------License # Phone <br /> Installation will serve: Residence [ Apartment'House,❑ Commercial ;[]Trailer Court C1 �1 <br /> .F Motel F-1 Other -------------- ---- -------- �1 <br /> ' Number of living units:_- /___-.- Number of bedrooms Garbage Grinder <br /> , �_ _ Lot size ----� �-- <br /> 'I' ' _-_Private r <br /> Y �e11%�-u � -- - ---- ❑ <br /> Water Supply: Public Sys m and fname.---___- <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ ay ❑ 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 /> 1i <br /> I' seepage pit permitted if public sewer is available within 200 feet,) �t <br /> NEW INSTALLATION: {No septic tank or <br /> PACKAGE TREATMENT { ] SEPTIC TANK Size--_ - C��_ ---__-_____- hiquid Depth _--_ ------------­-- <br /> Capacity TYPe�Y�� Material �o. Compartments --- <br /> Distance to nearest: Well -----�---------------------Foundation - -------- Prop. Line - `r_ --- .--_--.-•_ <br /> LEACHING LINE [ j No. of Lines _ - ------- Length of ach line----_o _ -----__ Total Length <br /> D' Box - _ Type Filter Material epth Filter Materia _ --- _______________ <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 <br /> ---------------------•-- ----- <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ..------------........ <br /> € '� ------) <br /> REPAIR/ADDITION(Prev.;Sanitation Permit# -------------------------------------------- Dafie ______.-________----____-- _ <br /> I <br /> Septic Tank (Specify Ri�quirements) -------- ------------ ---------------------------------- ------------------------------ ----------------------1--------------------------- <br /> Disposal <br /> ---------------• ------••- <br /> Disposal Field {Specify Requirements) --------------•----------------------------------------------------------------------------------------------.-------- --------------- <br /> ------- <br /> J (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 Son Joaquin Local Health District. Home owner oricen- <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 beco eu ject to W. *rkm,n' Co nsation laws of California." <br /> Signed -------------- - t Owner <br /> --- ------ I -- ---------- <br /> t <br /> Title <br /> ---------- <br /> By ------------------ ---- - ---- -- ------------------- <br /> (If other thian o. ner) <br /> II F R DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BYDATE j -----------<7------- <br /> BUILDING PERMIT ISSUED ------------------------------------------ <br /> ---------------------------------- ---------------------------------------- -------DATE ------------------------------------------- <br /> ADDITIONAL COMMENTS - <br /> ------------------------- ------------ ! 7- -��--------- �� - - --- ---- 4 <br /> -------------------------'1------------------------------------ ------------------------ -------- <br /> - 'I Z - ------ -------- ----- -- <br /> '°Final Inspection bY: !! - ------------------------------------------------- ------.Date ----- � = ���� <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT ' <br /> E. H. 9 T-'68 Rev. 5iM. <br />