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FOR OFFICE USE.: <br /> Q/1a�7� '3 Q APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit No. <br /> -- <br /> Date Issued _____'___ _______.. <br /> ________________-_______________-___._______________ 1 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 compliance with Count Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION . 1------E ---------- <br /> Al��---------------------------------------CENSUS TRACT --------------.-.......... <br /> Owner's Name / / - r---------1�;r_x? ----------•-•---- ------------------------------ ------------------Phone b 3- <br /> Address ---1,3L__-.101-Al?, ----------------------------- ---------------- City _,57- ---------------------------------------•---•-- <br /> Contractor's Name '______s 7__�_'_----------------------License #177S-g-3--_ Phone - <br /> Installation will serve: Residence�K Apartment House❑ Commercial ❑Trailer Court I❑ <br /> Motel ❑Other -------------------------------------------- <br /> Number of living units:_________ Number of bedrooms _____Garbage Grinder V-0-- Lot Size --------------._________________________ <br /> Water Supply: Public System and name --------------------------------------------------------------------------------------------------------- -----Private ❑ <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe4R 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.) G1 <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK,[ ] Size----------------------------------- ------------ Liquid Depth _____________-_____-_-- <br /> Capacity .------------------ Type -------------------- Material---------------------- No. Compartments ...................... <br /> Distance to nearest: Well _________________________Foundation ____ ----------------- Prop. Line ________________------ <br /> LEACHING LINE [ ] No. of Lines ------------------------ Length of each line---------------------------- Total Length ,____..______--__.___-_._. <br /> 'D' Box ___________ Type Filter Material ___________________Depth Filter Material ___________________._--_._--------_-.___..- <br /> Distance to nearest: Well ________________________ Foundation ------------------------ Property Line ........................ <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number ______________________ Rock Filled Yes '❑ No i❑ <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 /> Disposal Field (Specify Requirements) _____________ ___-___________ <br /> ' -I-C'----�, ------------------------------------------------------------------------------------------------------------------------------------------------------ <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, 1 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 ------------ <br /> Title <br /> (If oth an o r <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ----- --- <br /> - ---- ------------- ------------------------------------- ---------------- DATE ------------- <br /> BUILDING PERMIT ISSUED ------ -------------------------------------------------- ------------- ----------DATE --------- ---------------------- <br /> ADDITIONALCOMMENTS ---------------------------------------------------- -----------------•------------------------------------------------------------------ ------ ------------ <br /> ------------------------------------------------- ------------------------------------------------------------------ ------------------------------------------------------------------------- <br /> ------------------------------- --- --- - -- --- © +)CX <br /> -------------------------------------------------------------------------------------------------------- <br /> .. - ---- ------------ <br /> Final Inspection by: -- - --------------------------------------Date -----------__----------•------------------ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> Ci' <br /> E. H. 9 1-'68 Rev. 5M <br />