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'tr , <br /> FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> -� - ------------------------------------------ <br /> (Complete in Triplicate) Permit No. <br /> ---------------- <br /> -T 1-0 <br /> This Permit Expires 1 Year From Date Issued <br /> Date issued <br /> -------------------� -------------_--------------- <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/ c TION <br /> CENySUS TRACT <br /> - <br /> �-�Ownemf2-7 -----Phone J- <br /> ,Address Z / <br /> Name - �' � �L=_ 1_a1----- Phone <br /> ------.License - `---------- <br /> Contractor's <br /> 11 <br /> Installation will serve: Residence 9Apartment House❑ Commercial ❑Trailer Court ;❑ <br /> Motel ❑Other -------------------------------------------- <br /> Number of living units:_-_- ----- Number of bedrooms -_S'__-__-___Garbage Grinder --------- Lot Size ---------------------------------___________ <br /> Water Supply: Public System and name --------------------------------------------------------------------------- --------------•-------------•----Private <br /> Character of soil to a depth of 3 feet: Sand'[g 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 [ ] SEPTIC TANK [ ] Size________________ _______________ _________ quid Depth _____-_-__--_.--•_-______ <br /> Capacity -------------------- Type -------------------- Materi ------- o. Compartments ---------------------- ..� <br /> Distance to nearest: Well ____ _________ ______Foundation -.--________--_-___-__ Prop. Line •-_--_-__- ___-. -_� <br /> LEACHING LINE [ ] No. of Lines ____-___-_-____-__-_-_ Length of a line------------ __________-_ Total Length ----------- ................o0 <br /> D' Box ____.___ --- Type Filter Material ___ _____________Dep Filter Material ____________________________________________ <br /> Distance to nearest: Well _________________ ______ Foundat' n ____________--__--__.___ Property Line ____._.._.__.___..._.... <br /> SEEPAGE PIT [ ] Depth __-_ --------------- Diameter ___ ___________ Nu er ___-.____-__-____-___--__ Rock Filled Yes '❑ No <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 /> Diy <br /> (Specify Requirements) �__ __ _�______,__ ----______ __ --- r- t_ _ __t <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 /> I - mpensati.on lauds of California." <br /> Signed ------ <br /> --- ----- / Owner <br /> as to become subject to Workman's o <br /> BY ---------- -- ------- - ( Title - <br /> (If other thbn owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY � = -- ------- --------- --------------- --- --- ----- DATE ----- <br /> BUILDING <br /> --BUILDING PERMIT ISSUED ------------- ---- ----------------- --------------DATE ------------------------- <br /> ADDITIONALCOMMENTS --------- -------------------------------------------------- -------------------------------------------------=------------------- ------- <br /> --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------- --------- <br /> --------------------------------------------------------------------''------------------------------------------------------------------------------------------------------------------------- ----------- <br /> KA <br /> -- - -- -- -- <-- ----------------------------------------------------------- <br /> ----------- - -- ---- --- -- - - =- <br /> -- ----------- -- -- <br /> Final Inspection by: - -------------------- - F -------------------------------------- ------------------Date --- - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT C T3 <br /> E. H. 9 1-'68 Rev. 5M �.._./ <br />