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FOR OFFICE USE: <br /> ----------------- APPLICATION FOR SANITATION PERMIT <br /> �--------------------- Permit No: -------- <br /> ;, (Complete in Triplicate) <br /> J Date Issued <br /> _._..____._______ ._! _ _ This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to the San Joaquin-Loca1...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/LOCATIO --- <br /> ir <br /> --- ------------------------- -CENSUS TRACT ---------------------...- <br /> Owner's Name ---------- ----------------------•• - -------------Phone __V-'7°77-7q-q <br /> Address1Z - --- .-----------. city ---------------- ------------------------ <br /> p <br /> Contractor's Name .---- - - ----------------------- --------.License # 400-��-------- Phone <br /> Installation will serve: ;.Residence-[Apartment House❑-Commercial.0Trailer Court.;❑ <br /> Motel ❑ Other -------------------------------------------- ) <br /> Number of living units----- Number of bedrooms ----r_____Garbage Grinder LotSize1___�0",_�_1--'""k--------- <br /> Water Supply: Public System and name ______________ <br /> --------•----------------------------- - - - L.�_ ------------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat;❑'4 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.) `n <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT SEPTIC TANK`' t;,.: . ________ Liquid Depth _________. <br /> [ } t [ } .� � � Size-- � -- ��---------------------------- -------------- N� <br /> Capacity ----------- ------ TYpel-------------------- Ma#erial---------------------- No. Compartments <br /> Distance to neq st .Well ------------------------------------Foundation ---------------- ----- Prop. Line ----- ---------------- <br /> LEACHING LINE [ ] No. of Lines --------- -\_____-__ 'Length of eachline____________________________ Total Length .------_-..----__ <br /> 'D' Box ------------ Type Filter Material --------------------Depth Filter Material ----------_---__---_.-------------.-._-.--.- <br /> Distance to nearest: Well _______________________ Foundation ---- ------------------- Property Line ______-__----____--_--- <br /> SEEPAGE PIT [ Depth Diameter able Dept _______,_____ . Number ____________________________ Rock Filled Yes '❑ No i❑ <br /> :. , <br /> Water Th ° ~r= Rock Size <br /> Distance to nearest: Well;---------------------------------------Foundation --------------------- Prop. Line ______________________ <br /> REPAIR./ADDITION{Prev. Sanitation Permit# _`______________________.______.____.__ Dater-- -___— :- <br /> Septic Tank (Specify Requirements) -----------------=x------------ -----------.-------------------------------------------------- ---- <br /> Disposal Field (Specify Requirements) ---- Gtr- �tii �Q, - __ ____- <br /> ---------- ----- --------------------------------------- --- ----- 1 <br /> ,ti'� z � t <br /> ------- ---- -- --- - - - --•----=------ --- <br /> )' (Draw_existing,andzrequired addition on reverse side) <br /> I hereby certify that I have prepd ed-'nth s application andthatthe 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: ; ­_ -4 <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 ------ '------------�-- -- ---- Owner <br /> By * -- - . -------------------------------------- Title ------------- - <br /> f oth than owner) t = <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION AC EPTED BY - ------ ------ - -------------------------------------------------------- DATE ------ ---------- <br /> BUILDING PERMIT ISSUED --------------- - - --------- _DATE -- -----------------------------•----••-•- <br /> ADDITIONAL COMM EN. ------ <br /> -- � ------- ----- ��� _ .._ - --- ----------- --- ------- ........................... <br /> -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> i .:. <br /> Final Inspection by: ----- V f 1"_ ? *�t ,"�" S a - <br /> --------.bate _.. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> i� <br /> E. H. 9 1-'68 Rev. 5M <br />