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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> - =- ----------------- --- Permit No. <br /> (Complete in Triplicate) <br /> ------------------- - - <br /> - ----------------------------------------------------------- <br /> --______________ --__ _ _ <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 made in/compliance with) County Ordinances No. 549 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION ..I�!�R!__-------c5------T�--CJS?-�---- ------CENSUS TRACT -----------©-------------- <br /> Owner's Name Y-21--------- <br /> ,P � ,/ ----------------- -------- <br /> ---__-------------------Phone d-�- ---3yb <br /> La <br /> Address l- - l am✓ --------------------------- City / f _r r ------------ -- - C?� � <br /> t` <br /> Contractor's Name __ _-_ -�'_. _ _ / --------License z-_-_ --- ------ Phone i /`� <br /> -- ------------------ <br /> Installation will serve: Residence 1)9 Apartment House❑ Commercial ❑Trailer Court I❑ <br /> Motel ❑Other --------/-�----------------------------------- l �^ <br /> Number of living units:--- _._ Number of bedrooms __/[......Garbage Grinder _- __-_`-__ Lot Size !_- t� .------------- <br /> Water Supply: Public System and name ---------------------------------•------------------------------------------------------------------------.-Private <br /> IM <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 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 [ I SEPTIC TANK'[ ] Size--------------------------- -------------------- Liquid Depth -------------------------- 3L <br /> Capacity -------------- ---- Ty -------------------- Material--------- ------------ No. Compartments ---- ----------------- <br /> [ ] Distance to nearest: We -___.__g-_-_____________________Fours ation _.-------------------- Prop. Line -------------_------ <br /> LEACHING <br /> _____.__- _________ <br /> LEACHING LINE No. of Lines __-_-___.-___-_ __ Length of each line------ --------------------. Total Length ------.___-_ <br /> --------------- <br /> 'D' Box ---- ------- Type Fil er Material --------------------De th Filter Material --___.-______._.__________________....... <br /> Distance to nearest: W I _.---------------------- Foundatio __________________-_-__ Property Line ____.-_..-____..------ <br /> SEEPAGE PIT [ ) Depth --_________________ D' meter ____._____-__-_- Number --_.___--_-_--______-__ Rock Filled Yes ❑ No 0 <br /> Water Table Depth --- ------------------------ ------------------- ck Size -------------------------------- <br /> Distance to nearest: II ________________________________________ oundation -------------------- Prop. Line ____._---_-___-_.___._ <br /> REPAIR/ADDITION(Prev. Sanitation Permit <br /> to ) <br /> Septic Tank (Specify Requirements) ----------------------------------------J /h J / - ,..---------- <br /> Disposal Field (Specify Requirements) ._�Uj �!_--"_-____��-------1�f' ---- -- �`�'1 �----1 e---------- <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 Workm n's Compensation laws of California." <br /> Signed - �--------------------------- Owner <br /> ' � _Z-Y- --------------------- Title ------------------ ---------------- <br /> ---------------------------------- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ---- __ DATE __ - ' v_-__________-__ <br /> BUILDING PERMIT ISSUED __------------- ____.___.___DATE _--_-_____._-_______._________-___.. <br /> ---- <br /> ADDITIONALCOMMENTS ---------------------------------------------------------------------------------------------------------- ----------- ------------------------------------- <br /> ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -- -------------------- <br /> - ----- - - - - - - - - - - - - - - - - - ----------------- <br /> ------------------------------------ -- ------ ----- --- - - -- ----- --- - - -- - -- - --- -------- ---- <br /> Final Inspection by: --- ----------- ---- f Date -/6- ----------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />