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FOR OFFICE USE: �' 4 <br /> ' APPLICATION FOR SANITATION PERMIT <br /> I� (Complete in Triplicate) Permit No. <br /> ------------------ - - ---- ------------- - - Date Issued <br /> _______�_____ This Permit Expires 1 Year From 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/LOCATIONI,--- --,----_%.9�__ ----Z-ffe_e-1----- ;: 10..10 --__CENSUS TRACT ----------------- -•--- -- <br /> 77�0/ Z41 <br /> Owner's Name At LNC_h- _ed✓-------------------------------- ----------- ---- ------------Phone� -`- �' <br /> Address <br /> '� 'th 11l D = ---------------------------------- City'��/1----J sx ----------------- -- <br /> Contractor's Name ---0x�---•- j' 11 -----------------------------------License Phonea___6s7 <br /> ly <br /> Installation will serve: Residence ❑Apartment House❑ Comm tial :❑Trailer Court ❑ <br /> Mote! ❑ Others __ <br /> Number of living units:-__ ____ Number of bedrooms _!-_____Garbage Grinder ------------ Lot Sizer `�rT ` <br /> Water Supply: Public System and name ---------------------------------•------------ -----------------------------------------------•---------------Private rK <br /> Character of soil to a deptliM of 3 feet: Sand Silt[] Clay ❑ 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: (Nio septic tank or seepage pit permitted if public sewer is available within 200 feet,)f <br /> PACKAGE TREATMENT_ [ ]! SEPTI TANK'[ ] Size----6__K_4" _J1_ Liquid Depth -7,�________ <br /> Capacity _____ Type _ Mafierial_Crr,_ N` Compartments j.......:.... N <br /> Distance to nearest: Well _____& __________Foundation _/-- p <br /> ---------------- Pro Line <br /> [ ] IM. of Lines-_ __________ Length of each line____,_______________ Total Length --------------------- <br /> N <br /> LEACHING LINE N� ----- ---- - � _. � �� ------�----- ----- --------- <br /> QI` Box __________ Type Filter Material ______________Depth Filter Material -______ <br /> Distance to nearest: Well _-> _ ___--------- Foundation l4_______________ Property Lime. A1 _________-_____ fi <br /> SEEPAGE PIT [ ] Depth ___________________ Diameter ________________ Number ---------- Rock Filled Yes [] No 0 <br /> Water Table Depth ------------------------------------------------Rock Size -------------------------------- <br /> Distance <br /> -------------------------------DiItance to nearest: Wel! ----------------------------------------Foundation .------------------- Prop. Line ---------------------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------- ------- Date __________________________________) i) <br /> SepticTank (Specify Requirements) --- --------------- -------------------------------------------------------------------------;------------- -------------------------------- <br /> DisposalField (SpecifyRequirements) ------------------------------------------------------------------------------------------------------------- -------I--------------- <br /> -----------------------------------------------------------•------------------------ P^ <br /> ----------------------------------------------------------- <br /> (Draw existing and required addition on reverse side) <br /> I 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 Workm 's Compensation laws of California." <br /> Signed ------ ----- -----I� --------------- a Owner <br /> --------- --- - ----- <br /> BY --- - ------------ ---- ----- ----`— - ----------- Title ---------- --- <br /> (If other than'Cowner) <br /> II FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -------------- -----"-----' ( --------------------------------------------------- DATE ------- ----------- <br /> BUILDING PERMIT ISSUED'M------------------------------- --- ------------------------------ <br /> --------------------------------------DATE ------------------------------ <br /> ADDITIONAL COMMENTS iM <br /> --------------------------------------------------------------- <br /> ------------------------------------------- ----------------------------------------------------------------------------------------------------------------- <br /> --------------------------------------------- ------------------------------- ----------------------------------------------------------------------- ---------------------------------- <br /> II - <br /> -------------------------------- -------- -- - <br /> Final Inspection by: ------- ----------------------------.Date - --------- --- --------------`-------- ---- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT { <br /> E. H. 9 1-'6$ Rev. 5M G� <br />