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FOR OFFICE USE: Pm <br /> .� ,... APPLICATION FOR SANITATION PERMIT <br /> Permit No. ___7-_ <br /> V 0. (Complete in Triplicate) 3!� Z <br /> --------------------- -- -t--------- -- ------------------ <br /> , f <br /> _---___________ ___________- This Permit Expires 1 Year From Date Issued 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 de in compliance with County Ordinance No. 54 an xisting l 117,es nd a ulations: <br /> JOB ADDRESS/LO TION _1?4- _ -- -- *�--- �-- --- -- �A��,�- -- ------------CENSUS TRACT�1_e)-------•----------- <br /> Owner's Name ------ I- ----- W-111---- ----- -4--------- Phone <br /> _ ---- ---- <br /> , i---- ------------------------- Cit G a ------------------------------------------------------- <br /> --I.. <br /> °--------------------------------------------•---•-- <br /> Address ---------------------- �-�-�-�---C`--`--`�'�--`--------- Y --------------------- <br /> Contractor's Name ____ _-•i ____.License #�?�� - ------ Phone <br /> - S <br /> Installation will serve: Residence partment House,F Commercial []Trailer Court ❑ <br /> Motel ❑ Other ------------------------------------------- <br /> Number of living units:_-_-( Number of b ooms '2---__.Garbage Grinder 4- ___ LotSize _X_/a �1____________________ <br /> Water Supply: Public System and name ------- -- -aq------���L'�4-,__�-�.----------------------------------•-----------_____Private ❑ <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe [j6­lill Material ZV-0 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: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) / <br /> PACKAGE TREATMENT [ ] SEPTIC TANK ze______��_-X_S` _:_ __________________ Liquid Depth _�.�------_____- <br /> 4 <br /> Capacity �. - --- Type p,,-- ' '[_ Material�w- o, Compartments ---2_.......... <br /> D' Lance to nearest ----------------- <br /> Well ___ � Foundation ---/--f.__-__.__ Prop. Line _ � <br /> ------------------ <br /> LEACHING LINE No. of Lines -------- ______________ Length of each line---- ---------- Total Length ' _�.____..____ <br /> 'D' Box Type P ! � c, _ <br /> __ ..u__ T e Filter Material _2!_� "'____De Depth Filter Material _____ ___ _________________ ___._ <br /> Distance to nearest: Well __I�t.�_ = Foundation l_10I___-_-___ __ Property Line____________ __------ <br /> .T . <br /> SEEPAGE PIT N--" Depth _s1-�________ Diameter �_(c___l____ Number _ __ -. �____ _. Rock filled Yes 'U,-- I�o 0 <br /> • i <br /> Water Table Depth -------- _ ---------------------------Rock`Size /__Z-X__ ___-_-__-_ <br /> Distance to nearest: Well ---- -_________________Foundation ------- 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 /> I hereby certify that 1 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, 1 shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed Owner <br /> Nne <br /> - -------------------- <br /> BY ------------------------------------------ L/� ---------------- Title ---- ''� ----- ------------ <br /> (If other than o <br /> FOR DEPARTMENT USE ONLY c <br /> APPLICATION ACCEPTED BY DATE ----IA- --`SIA1 -------------•--- <br /> BUILDING PERMIT ISSUED __. ___ _________ ______ DATE -_____.--___ <br /> ADDITIONAL COMMENTS -------------- --- ----- ------ <br /> --------------------------------- <br /> ---- �j� - ---------------- <br /> ------------------------------------------------------- ------------------- ---- ----------------------------- <br /> -------------------------------- - -- ---- --------•------- <br /> ------------------------------------------ ---- ------------ ------ --- <br /> - - - - - - - - - - - - ------ ---- - -- <br /> FinalInspection by: ---- --------------------------------------------------------------------------------Date j �-------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT IQ—%3 kn <br /> E. H. 9 1-'68 Rev. 5M <br />