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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> • ----•---------------- Permit No. <br /> (Complete In Triplicate) <br /> ---------.................................................. 4This Permit Expires I Year From.Da#e Issuedry_ N wDoti Issued /..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 compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/ OCATION ....._.._.. 4 a''4................... ......................CENSUS TRACT 4' .:... <br /> Owner's Name ------S/._!.j.'et!.............`.............................. ....:............,...Phone 36� �?. ...._.. <br /> Address . , ._.�T�/?1 __.........I.............•.. City ../ i4-n r..................._......._.... <br /> .,...:.. <br /> Contractor's Name G... , -.............................License .?V_........ Phone <br /> installation will serve: Residence R-Apartment 'House fl Commercial ❑Trallor Court 0 <br /> --Motel Q-Other ................. <br />. Number of living units:-........... Number of bedrooms -,3_....Garbage Grinder ............ Lot Size ..:............:..... ................. <br /> Water Supply: Public System and name .............................-...........-..-_._ _-:...........................................Private [D <br /> Character of soil to a depth of:3 fee#: ` Sand❑ Silt 0 Clay ❑ Peat❑ Sandy Loam J2/, Clay Loam Q <br /> 'Hardpan Q Adobe 0 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 /> k NEW INSTALLATION: "(No septic tank or-,seepage pit permitted if public sewer is available within 240 feet,) <br /> PACKAGE TREATMENT ( } ,,SEPTIC TANI'f j Size.......•........................................_ Liquid Depth .......................... <br /> . V <br /> Capacity f-----'........ Type -------------------- Material....................... No. Compartments ­.............. <br /> s�l <br /> Distance to nearest:';Well _..................................Foundation...................... Prop. Line....................... <br /> LEACHING LINE ( j No. of Lines ----------------- ------ Length of each line............................ Total length ............................ <br /> 'D' Box ...... TypeFilterMaterial ....................Depth Filter Material ............................................ <br /> Distance to nearest: Well ........................Foundation ........................ Property Line ........................ <br /> SEEPAGE PIT [ J Depth ------ ------------- Diameter --------------_ Number ......................... Rock Filled Yes ❑ No 0 <br /> Water Table Depth .......fi ...... ........Rock Size ................................ <br /> Distance to nearest: Weil'-r-.----------._�.................::foundation,•..-.-...= _Prop. Line ............. <br /> .._..,.-- <br /> REPAIR/ADDITION(Prev. Sanitation.Permit ` _..............._-.�__ ----=----------__ Date ..-_.-__.-- ............j . I <br /> Septic Tank {Specify Requirements).. ' <br /> Disposal Field (Specify Requirements) ------- _ i �-:-- -�_.--�(__`c-__1 ...'................ .......... <br /> �� h � <br /> '................ ............. <br /> .._.._..._.._._...... <br /> '(Draw existing and required addition on reverse side) ' <br /> 1 :hereby certify that 1 have-prep'ared this application and that the work will be done ln: ``accordance with San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin local Health,Dlstrict. Home owner or liter- <br /> sed agents signature certifies the following:` k j' <br /> "I certify that in the performance of the.wark for which this permit is issued,_I shall not em_pipy any,person in such manner <br /> as to become subject to krompensation laws of California." <br /> Signed _--- - -------- ----- ---- * Owner.____-___••___•_------F_•_-__•__-___.____•_•• QBY ----.. ---- -- ---- ----- ••---..._....- --•- ------ Title ---- .... ----- ._.---- ... <br /> er than <br /> f R 9 f PARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ---•---- ----- ...................... --------- • ----:-. DATE.;:. ....3 -.----.:.- --- <br /> BUILDING-PERMIT ISSUED ------------y"----------------------------••-----•-•--•---•------ ------------- --- --.....---------DATA - .................................... <br /> ADDITIONAL COMMENTS --------------- ------------------------ ..................................... <br /> • ---------------- ------------------------------------------------------------- ------------------ -�--....._.:-..------ --- -•-------...... -------------------•------ <br /> ---------.----------------------------- ------ - ------- ............. .......... ............. <br /> Final Inspection by ;f .: ... '_ _...Date .a I .'. <br /> EH 13 2h 1.68 Rev. 5M SAN JOAQUIN .LOCAL HEALTH DISTRICT . ,� 8/7h 3M <br />