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FOR OFFICE USE: <br /> �J APPLICATION FOR SANITATION PERMIT <br /> Permit No: <br /> ILAZI (� (Complete in Triplicate) <br /> r----- 1-�? <br /> ________ _________________________________________ This Permit Expires 1 Year From Date Issued <br /> Date Issued --- <br /> Application is hereby made to the San Joaquin Local Health District for a per 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/LOCA�ThONle�:_A J/V' f.,lC - /4:.tom---_- -- --CENSUS TRACT ._-_--_............._ <br /> Owner's Name ----------------'Ina-'l�-e"—--- -------------------Phone ------------------- --- -•--•-•---- <br /> Address ------- � T. - - ----- -------- ----------------- ---•-----•--- City _ __/�1� /L'/%�----------------------------------------- <br /> Contractor's <br /> ------ •----•--f--- <br /> Contractor's Name __ � ' --------------------------------License #WI314 �:_ ---_ Phone <br /> Installation will serve: Residence Apartment House❑ Commercial ❑Trailer Court ;❑ <br /> Motel ❑Other ------------------------------------------- f <br /> Number of living units:---/---- Number of bedrooms -_ c....Garbage Grinder/�/iC,_.__ Lot Size%Q. ./_/pe.................... <br /> Water Supply: Public System and name __ 416A__.-__ Q'I- ----------- �- ---------------_--------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Gay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ AdobeX 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.) �U <br /> Ilk <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] Size------------------------------------------------ Liquid Depth -------------------------- <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 /> ------------•-----•-•--- <br /> SEEPAGE PIT [ ] Depth --_------_-------- Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No i❑ <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) ----------------- /------------------------------ / ----------------- <br /> Disposal <br /> ---------Disposal Field (Specify Requirements) �t�_..__�j� .__ <br /> 1 -4 <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 /> "1 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 -------------------------------- ---- - ----- � 1 ----------------------------- Title '< -------------------- ------------ <br /> (If other n owner) <br /> FOR DEPARTMENT U E ONLY / q <br /> a APPLICATION ACCEPTED BY - ---- --- - -------- -------------------- DATE 1 --- f- --- � ----- <br /> BUILDING PERMIT ISSUED -------------------------------------------- -------------------------------------------------------------DATE ------------------------------------------- <br /> ADDITIONALCOMMENTS ----------------------------------- ----------------------------------- --------------------------------------------------------- -------- <br /> --------------------------------------------------------------------- - -------------------------------------------------------------------------------------------------------------------------------- <br /> --------------------------------------------- -- -------- ---- ------ - - - -- - - - - - - - - -/-/- ,: <br /> ----- - - --- ----------- <br /> ------ - ---- ---- --- - -- - - -- <br /> Final Inspection by: -------------- Date <br /> - <br /> SAN JQUIN LOCA HEALTH DISTRICT C <br /> E. H. 9 1-'68 Rev. 5M <br />