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FOR OF/U : APPLICATION#OR SANITATION PERMITd <br /> --------------------- <br /> \ <br /> (Complete in Triplicate) Permit No. ------- <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 existignRules and Regulations: <br /> JOB ADDRESS/LO TON . r pr 0 X�rt�(Y�` EIVSUS TRACT ----- --- <br /> Owner's Name _ 11 e <br /> --/�-- ------- ------Q-�-�-..__._----------------------------------------------=---------------------Phone --- <br /> Address -7-6-7-4--- = ��� Cit <br /> K Q y ---------------------- <br /> Contractor's Name ____ ------------------------License # ----- ------------------ Phone __-_-_-____-_-___------•_- <br /> ----------Q--tail- 1�[ _ <br /> 7 <br /> Installation will serve: Residence E]Apartment House❑ Commercial ❑Trailer Court <br /> Motel ❑Other --------------------------- ---------------- <br /> Number of living units:------------ Number of bedrooms __________-_Garbage Grinder ------------ Lot Size __----� _-(_--^j-------- -� <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 <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 it permitted if public sewer is available within 200 feet,) ! ! Na <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ Siz !__d_'�_ _. _ _�_ __.7�`�.�`Liquid Depth ____ _ ---------- <br /> Capacity •Materi I_G_!�_ __ _No. Compartments -_-___.- // <br /> P y /�--Cr-c---- Type �Y---.--_.. v <br /> Distance to nearest: Well -___ ----- -------_--------Foundation _/0------------- Prop. Line ....... <br /> LEACHING LINE ,[ No. of Lines __ ___ ______________ Length of each line------ Total Length ---/_`f .............. <br /> 'D' Box _.:________ Type Filter Material � -.___.Depth Filter Material ____��}% �'` <br /> ��-----yy�� - - ------------------------•- <br /> Distance to nearest: Well ----J---"_-__:__ Foundation ____I_d ----�_ Property Line .._.,f �____....__. <br /> SEEPAGE PIT [ ] Depth ------._.---------- Diameter ________________ Number -------- ------------------- Rock Filled Yes Q No 0 <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 /> Disposal Field (Specify Requirements) --------------------------------------------------------------------------------------------------------------------- --------------- <br /> ----------------------------------------------------------------------------------------- - ---------- --------------- ------------------------------------------------------------------------ <br /> (Draw existing and required addition on reverse side) <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 e.performance of the work for which this permit is issued, I shall not employ any person in such manner <br /> as to beco ject to Wor n's Compensation laws of California." <br /> Signed - --- ------------------------------------------- Owner <br /> By --------------------------- - ------ - ---------------- Title --------------------------- -------------------------------------------- <br /> (If other than-owner) <br /> DEP MENT USE ONLY <br /> APPLICATION ACCEPTED BY .___-_-:_ -' _ _ _/ _-_____-___-__-_-__--______-_. DATE ___:_1J_ ------ <br /> BUILDING PERMIT ISSUED ---__._-__-/_____ _____ _ _____ __ -:DATE -___---___-__ ----------------- <br /> ADDITIONALCOMMENTS -------------f ----- ------ - ------ -- ------------ ---------------------------------------------------------------------------- -------------------------- <br /> ------------------------------------------------- --------- ------------------------------------------------------------------------------------------------------------------------- <br /> -------------------------------------------------`-7------------- <br /> -------------------------------------------------------------------------------------------------------------------------------------- <br /> ------------- ---------------------------------- -- Z------------- <br /> - - - - - - - - ------- - - <br /> Final Inspection by: --------------- _ - Date --- ------_ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />