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FOR OFFICE USE: y — <br /> APPLICATION FOR SANITATION PERMIT <br /> '. ..... ICohrpleto In Triplicate)s hermit..NA...� .�� .:.. .. <br /> ...... ..... .7J.: ........ This Permit Expires t Year from Date Issued Date Issued ........... .. <br /> ti <br /> 4 <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 complion a with Counnty,Ordinance No. 549 and existing Rules and Regulationsr <br /> JOB ADDRESS/LOCATION ...... f7.61.. , ? .1. 1 .. Y.....................CENSUS TRACC .. <br /> Owner's Name ... .k:..... k. .(`1.5 T_Q................................. ..........:.......:................Phone .� /..-.8�� '...:.... <br /> Address -... .0. ...:............ ....._........... . . ..rCity -r--CA - N...................... .. .. .. .. ......... <br /> Contractor's Name ......... r .:: .1;•pn, �z 1 t ........ ,o r�s;...: :!`L. ..........Liasnse ilz .......................... Phone ,5........... <br /> - .... <br /> Installation will.serve: Residence Apartment House fl Commercial❑Trailer Court ❑ <br /> Motel❑Other....................................... 4 - <br /> Number of living units,..../-..... Number of bedrooms ......Garbage Grinder ............. Lot Size° ....................................:... <br /> Water Supply: Public System and name ......... ....... ....... ........................ .. <br /> .. ...........................................Private(9 . . <br /> Character of$oil to a depth of 3 feet: Sand 0 Sift❑ Clay 0 Peat 0 Sandy loam C3 Clay Loamt <br /> Hardpan Adobe 99 Fill Material ............If yes,...........I.... ............ <br /> IPlot plan, showing size of lot, location of system in relation 'to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: 1No septic tank or seepage pit permitted if public sewer is available within 200,feet,! i <br /> PACKAGE TREATMENT 6 ] SEPTIC TANK; ] Size.':............... .......:................. liquid Qepth \.. .......... ... <br /> -- Capacity .................... Type ........ .. .... Notarial..................:.. No. Com :....• ........ J r <br /> Distance.to nearest: Well ......... .......................Foundation.............. .... <br /> LEACHING LINE { ]. No. of Lines ................I.......... Length of each fine............................ Total Length ............................ <br /> 'D' Box .....:. Type Filter Material ............... .Depth Filter Material .................................. ..... <br /> Distance to nearest; Well ............. ....... Foundation ........................ Property Line ....................... <br /> SEEPAGE PIT j Depth Diameter .................. Nuntiber ............I............... Rade Filled Yes ❑ No.Q <br /> Water Table Depth ................................................Rode$ize .................................. <br /> Distance to nearest: Well ............... .....................Foundation ................. Prop. Lige ............... <br /> REPAIR/ADDITION iPrev. Sanitation Permit# .... ..:... Date ...:.: ....} <br /> ...................... ..�.. •s• .. <br /> Septic Tank [Specify Requirements)..... Pf :. ....... .......... <br /> . . . <br /> ...._.....,.............._........... ... <br /> Disposal Field (Specify Requirements) ................`_--___:_:......:..................___._..... :.. <br /> :.... 4t ..........:. ... . ... ...... . . .... ... ...z 1 - .......... <br /> .. .-.... --•--•••.................. .................................. ----.--•......_.__.-._-........_........................:_....._.. <br /> .......................................... <br /> (Draw existing and required addition on reverse side) <br />'E I hereby certify that l 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 Saar Joaquin Local Health,District. Home owner. Of licew ' <br /> sed agents signature certifies the following: <br />` "I certify,that in the perf once of the wor for which liis permlt is Issued, 1 shadl not ompley'any person in sash manner <br /> as to becem vblect mq�n's Comp tion b of California:' <br /> 7 <br /> Signed --.......... �� -.. .. --• ........ ..... <br /> BY --------- <br /> title -.-. .. . . <br /> ....--- ----- <br /> llf other than awned , <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ... <br /> BUILDING PERMIT ISSUED .... DATE , <br /> ---------••------------------------------------------ <br /> ........ ........................... -....---......-.,.....-....----------...-._.-.....---DATE ..................................... <br /> ADDITIONAL COMMENTS ...................... <br /> ...........•.....:.......•------•-------•.-....._......-... • .............. - ------------.-....---.:.......... .........:...... <br /> I° --------------------------•---- <br /> ................................. ---•-•---....-.................................................... ....... .................................................... <br /> r, <br /> .....................------------ - -- ---- - - ------ ----- <br /> j Finot inspection bY: Date ... �.. :.... <br /> ..............•-•• ......-...-.... <br /> vc.-J <br /> - <br /> EH 13 21� 1-5 <br /> AN IOAQiJiN LOCAL HEALTH DISTRICT $/- 3M <br />