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FOR OFFICE USE: <br /> ,APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit No. <br /> ---------=----------------------------------------------- 4 // <br /> _ --- <br /> -------- ------------------------------------------------ This Permit Expires 1 Year From Date Issued <br /> Date Issued . --'_to _ _ <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 .l_r�­/­­-G2------- --- ' ----------------------------------------CENSUS TRACT --------------.----------- <br /> Owner's Name ---elf------_�'��_ ------------------------------------------------------------ -------Phone ------------------------------------ <br /> Addressf, � ------------- --. City ----- �P.fc s� -----------------------------------•---•-- <br /> Contractor's Name ------ 14,rz Gam___. ___ ____-- __ --------------License # ----- Phone _______-__-.--_-_-------- <br /> Installation will serve: Residence (Apartment House❑ Commercial ❑Trailer Court J❑ <br /> Motel ❑Other ______________________ <br /> Number of living units:_-._l____ Number of bedrooms _______Garbage Grinder ------------ Lot Size __ ___-__ <br /> Water Supply: Public System and name --------------------------------------------------------------------------------------------------- ----------Private <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam [� <br /> Hardpan ❑ Adobe ❑ Fill Material ____________ If yes,type ---------------------------- <br /> (Plot <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 fe Size-0,/'/_O` ---------------------- Liquid Depth -,V-Z.... <br /> % ----------- �r <br /> ao _ TypeC '�' -- Material--t - No. Compartments -.rte Capacity _/ \ <br /> Distance to nearest: Well ------------ -----------------Foundation ---.Log_!---------- Prop. Line ___S_ ___._---- <br /> LEACHING LINE [If No. of Lines ____r;2-------------- Length of each line--------Ave,---------- Total Length -------------- <br /> 'D' <br /> -.-.'D' Box ----y------ Type Filter Material ____5� t-----Depth Filter Material --------Op!---------------------------..... <br /> Distance to nearest: Well ---------.S.a___`------ Foundation -------/b----------- Property Line --- <br /> SEEPAGE PIT [ Depth -------- Diameter __5Vv?_"___ Number -------19------------------ Rock Filled Yes a] No 0 <br /> Water Table Depth ------------------------------------------------Rock Size -------------------------------- <br /> o <br /> Distance to nearest: Well _ /t1Q--------------------Foundation ---l__U------------ Prop.Prop. Line _- ------------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date __________________________________) <br /> SepticTank (Specify Requirements) -------------------------------------------------------------------- ------------ --------------------------------------------------------- <br /> DisposalField (Specify Requirements) ---------------------------•----- --------------------------------------------------------------------------------------------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------=------------------------ <br /> -------------------------------------------------------------------------------------------------------_--------------------------------------------------------------------------------------------- <br /> (Draw existing and required addition on reverse side) <br /> 1 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 Workman's Compensation laws of California." <br /> Signed ----- -- - ---------------� ------------- Owner <br /> ------------------------ <br /> ---------- <br /> BY �------ ------ --- ---------- Title _------~-� �V <br /> ---------------------------------------------- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY --`--,� A - DATES <br /> BUILDING PERMIT ISSUED ---------------------------------------------------------------------------------------------------------DATE <br /> ADDITIONAL COMMENTS -- - - - ------------ <br /> ------------------------------------ -------------- - -------------------------------- - ------------- -----------------------------------------------------0-------------- <br /> ------ <br /> Q------------------------------------------ ----------------------------------------- / <br /> Final Inspection by: ________ _____---_____--___ ____Date 0_ ---------------------------------- <br /> SAN <br /> --1_____ - _ - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />