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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT 1�0- <br /> ---------------------------- <br /> (Complete in Triplicate) Permit No. -1- <br /> Date Issued <br /> __ kJ_\ <br /> ________--__--_ _-_ <br /> _____._ _-____._.______-._.__-_ This Permit Expires t Year From Date Issued 1 <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/LOCPIA <br /> ION ___-_ ell{ ___-__`CENSUS TRACT __.-. <br /> ------- // /!/L�p <br /> Owner's Name ---- ------",0- ------ZPhone .rr±1__-_�C..T._/__ <br /> Address --------- - 7 `- ------------- ------- --------------------- --•-- y -------------------------------- ------------------------------------------- <br /> itContractor's Name ----- ------ _--- --- ------ License #f_CT� dt'--------- Phone 7�Q' �'-rbc------- <br /> Installation will serve: ResidenceApartment House❑ Commercial ❑Trailer Court i❑ <br /> ll Motel [-]Other -------------------------------------------- <br /> Number of living units:-___/----_ 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 /> (Pl'ot plan, showing size of lot, location of system in relation to wells, buildings, etc. mast 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------_--------------------------------------f__ Liquid Depth ___.___..____-_____.-..__ 11s. <br /> Capacity ------------------- Type -------------------- Material--------------------- No. Compartments -----------------_-- <br /> Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ...................... <br /> LEACHING LINE [ No. of Lines ______________________ Length of each line---------------------------- Total Length ---------__-,___------__.-__ <br /> 'D' Box .----------- Type Filter Material .___--__.-._______Depth Filter Material __: --------------------- <br /> Distance to nearest: Well ________________________ Foundation ------------------------ Property Line ----------_-_-------- <br /> SEEPAGE <br /> ___--__-- __- ___._.-_- <br /> SEEPAGE PIT [ ] Depth -----------------.-- Diameter ------------ --- Number -------- ------------------- Rock Filled Yes '❑ No 0 <br /> Water Table Depth ------------------------------------------------Rock Size ------------------ --------- <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ---------------------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------). <br /> Septic Tank (Specify Requirements) -------------- T -------------+---•---,..---------------- ---------- <br /> Disposal Field (Specify Requirements) -- <br /> ---- ��----- ---------- - <br /> . <br /> ---------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------- <br /> (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 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 /> By ----- ---- ---- ------- ---------------------------------- Title -------------- ----- ---------------------------------- <br /> ---- -- ---------- - - - --- -- <br /> (If other owner) <br /> FOR .DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ------------------------------------------------------------- DATE —1-.��r o---------- <br /> BUILDINGPERMIT ISSUED ----------------------------------------------------------------------- ----------------------DATE -------- ------------------- ---------- <br /> ADDITIONAL COMMENTS ----- _ -__/________ _ ��_ _.___ ______________ <br /> - h ------------------------------------------------------------------------------- ------------ ------ `--- ------ <br /> --------------------- <br /> ------------------------------- <br /> ----- <br /> ------------------------------------- ----------- -------------------------------- -------------•--------------------------------------- <br /> .,SAN <br /> - ---- <br /> ------------------------------- - - - ----- - ------- -- -- ---------------------------------------------------------------------------------- <br /> Final Inspection b - Date ----- <br /> ----------------------------------- <br /> � , <br /> P y: - �- - <br /> - -SAN JOAQUIN LOCAL, HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />