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FILE USE: APPLICATION FOR SANITATION PERMIT <br /> --------- �� ' /ate° <br /> rt , <br /> Permit No. __.____ ----------- <br /> Womptite in Triplicate) <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 compliiaa ce with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION _' `. __ ____ Lf -------------------------------CENSUS TRACT __________............ <br /> Owner's Name Ca'- 4 ----- .--NO-_ltt-------------------- j�l- -----Phone o�` a ...... <br /> Address ----- � - ",�-------W_Cd - ------------------- --- City !�_I"_r1 { c� ��� .----------------------- ----- <br /> Contractor's Name , _f�Lt.l�_c-�4 iA-------------------------- �� � <br /> License #02_��•� --- Phone <br /> Installation will serve: Residence PJ Apartment House❑ Commercial []Trailer Court i❑ <br /> J Motel ❑Other ------------------------------------------- <br /> Number of living units:---!_-_____ Number of bedrooms __t.Q-___Garbage Grinder ---- Lot Size -'--.____-__. <br /> Water Supply: Public System and name --------------------------------------------------------------------------------------------------------------_Private ❑ <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt F] Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe I$ 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: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK[ ] Sffizej _________-_. Liquid Depth ._� � T� <br /> Capacity/ZOO_O---__ Type 1�'fi-�'_I`_/?_.�.c_ Material No. Compartments _a.............. <br /> Distance to nearest: Well ......�e __. _________ Prop. Line ----_______ <br /> LEACHING LINE [ ] No. of Lines ..__--c!:2----------- Length of each line________5�� ----------- Total Length ____� -- _____ <br /> ---- <br /> ff ll ��ii�r <br /> 'D' Box ___ ----- Type Filter MaterialXC-$ 1ftf�.Depth Filter Material ----l-4_-___________-------------_---- <br /> ___ _______________ <br /> Distance to nearest: Well ------- --------- Foundation _.r -------------- Property Line __ -________________ <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 /> SepticTank (Specify Requirements) ------ ----------------------------------------------------------------------•------------------------------------------------- -------- <br /> DisposalField (Specify Requirements) --------------------------------------------------------------------------------------------------------------------- --------------- <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 -------- __ ____, al <br /> Owner <br /> ,. � � - �, <br /> - - ------------------------------------------- <br /> BY f ��'� = <br /> ------------- ----------------------------- Title C LQr �` <br /> (If other than wrier) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY __________________& �O S �. <br /> --- ------------------------------- ----------------------------------- DATE ------- ---------- ---�------------------- <br /> BUILDINGPERMIT ISSUED ----------------------------------------------------------------..--------------------------------------DATE ------ --------------------------------- <br /> ADDITIONALCOMMENTS -------------------------------------------- -------------------------------------------------------------------------------- --------------------------------- <br /> ------------------------------------------------- ------- - <br /> --------------------------------- - <br /> Final Inspection bV - ,�' ------------------------ ------ ----------Dateff - ---- -� <br /> p Y1 �� <br /> SAN AQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />