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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> ----------------------- (Complete in Triplicate) Permit No. ._._______ _--_--. <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 Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION ___ ,____ �/_ 4___---?_______l/__�._R f CI_� ______CENSUS TRACT <br /> J <br /> Owner's Name l / ' C. 4 C'_r?_1 _/ <br /> ---------- - Phone <br /> Address _ t�.� sty" /i z�p L'.__?—/_:. � - - ------------------- City d f_�!1� '_ ----_----------------------------------------- <br /> Contractor's Name ---___ ��.___.____Cf�_f_�_f�'_/�_ f 3:�`S= - <br /> -------------------------license #o._y3f_'------------ Phone _ _ <br /> Installation will serve: Residence [RApartment House❑ Commercial ❑Trailer Court ;❑ <br /> Motel ❑ Other -------------------------------------------- <br /> Number of living units:-------I--- Number of bedrooms -3------Garbage Grinder ___________ 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 ❑ 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 sew r is available within 200 f t,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK[ ] Size----------------------- _____________________ Liquid pth ______________--__--___. W <br /> Capacity -------------------- Type -------------------- Material--- ---- ------------- No. Co artments .---••----•----------- CN <br /> Distance to nearest: Well ______________________________-_.- oundation ___-__________ _____ Prop. Line -__-___-__-_____-_---- <br /> LEACHING LINE [ ] No. of Lines _-_____-._______-__ Length of each Ii -------- ------------------- tal Length ,___________________________ <br /> D' Box ____.______ Type Filter Material ____________ ______Depth Filter M erial __________________..________.,__._._..._.__ <br /> Distance to nearest: Well ________________________ F ndation ____.._._..__ _________ Property Line _________________......_ + <br /> SEEPAGE PIT [ ] Depth ____________________ Diameter ____________ _ Number .-.__--__..__ ____-____-__ Rock Filled Yes '❑ No 0 <br /> Water Table Depth --------------------------- -------------_---Rock Siz -----------------------------•. <br /> Distance to nearest: Well ______________ ________________________Found tion _____-_--__-_-______ Prop. Line ......_.__.__..._.____ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# _________________ __________________________ Date ----------------------------------) <br /> SepticTank (Specify Requirements) -------- ---------------- ----------------------------------------------------------------------------•------------------------------------- <br /> DisP4salField (Specify Requirements) --------------------------•-------------------- -------------------------------------------------------------------- --------------- <br /> 7�a ���.�v/�_�d �� --' �✓ C-rd�__c1 _ _ � __ - rf�G— !i/c✓v { <br /> - - <br /> --- - � ---- -- -------------------------- --te <br /> �v ---'�-- ----- � -------- -- <br /> (Draw <br /> r <br /> existing and required addition on reverse side) �Lid�°1r <br /> I hereby certify that 1 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 bWsubjecto man's Compensation laws of California." <br /> Signed --------- Owner <br /> BY - L Title . - ------------ --------------------------------------- <br /> owner)/ <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ----- f `---------------- ------------------------------------------------- DATE ----------`--_ L. ------- <br /> BUILDING PERMIT ISSUED --------------------------------------------------------------------- --------- ---------------------DATE ------------------------------------------- <br /> ADDITIONALCOMMENTS ---- --------------------------- ---- ---- - ---------- -------- ---- --------------------------- ------------------------------­--------- <br /> ------------------------------------------------- - --- - -- --- -- -- -----------------I-------------------------- <br /> I <br /> % - <br /> -- <br /> Final Inspection b - 1=G` / = - =------ ---------- - ------Date _. _ � -------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />