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FOR OFFICE USE: ! ` ^ <br /> �,.., APPLICATIOW FOR SANITATION PERMIT <br /> ------ .- " r:" �,�" ` z Permit.No- - <br /> ` i`�. <br /> (Complete iri'Triplicote)'4 - <br /> ---------=---- ------------------------------------------ <br /> : k . . <br /> Date Issued _---"_��` <br /> ------------------- --------------------------------- A Thls 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 County rdinance No 549 and existing Rules and Regulations: <br /> r <br /> JOB ADDRESS/LOCAT ------------------_--/- <br /> - CENSUS TRACT ----------------- -------- <br /> Owner's Name _._- PS S ---------ele. ------------ --- ------- --------------- -------Phone ---------------------------- ----- <br /> Address ------------------------ ----=--- r u -- ----- City a----------------------------------------- <br /> Contractor's Name --- ---------------------- ------.License #16_,�Q_ WQ--Phone - -- - -------- ---- <br /> Installation will serve: Residence partment House❑ Commercial ❑Trailer Court ;❑ <br /> i. <br /> r Motel ❑Other -------------------------------------------- <br /> Number <br /> ------------------------------- ---------Number of living units:----!) Number of bedrooms 'Garba a Grinder Z-1,4'7- Lot Size _�`��_��� -------- <br /> Water Supply: Public Sys1€emland name e. -- Private ❑ i <br /> Character of soil to a depth of°feet: Sand❑ Silt❑ Clay Peat❑ Sandy Loam -❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe' Fill Material-• ___ If yes, type ---------------------------- <br /> - <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 sewer is available within 200 feet,) / <br /> PACKAGE TREATMENT{ ] SEPTIC TANK'[ ] Size____-----t------------------------------------- Liquid Depth __------_":_'______----_. l•v <br /> \ r'* r, \�) <br /> f�Capacity -------------------- Type ----------------�Matdricrl-------- === ` -No. Compartmentg ---- -•----` Q <br /> /Distance to nearest: Well ------ _____________________Foundation -.-_ ---- Prop. Line -------.-------- <br /> LEACHING <br /> __LEACHING LINE [ ] X;No'. of Lines ______________ _ Length of each line.______________------------ Total Length --------------- ------------ <br /> � r�'D', Box ------ ,.•Type Falter Material --------------"""---Depth Filter Material --------------------.---•_---------------- <br /> A <br /> Digtonce� <br /> -•"-- - --•-•_-- <br /> Digtonce� to nearest: Well =----------------------- Foundation ------------------------ Property Line ------------.-----.-.--- <br /> SEEPAGE PIT [ ] Depth �- ........... Diameter --------------- Number ---------------------------- Rock Filled Yes ❑ No i❑ <br /> i WaferTable Depth--- --------- <br /> ---------------------Rock Sze ---------------------------- r <br /> v <br /> Distance to nearest: Well ---------"`_----------------------------Foundation -------------------- Prop. Line ____------____._____.. <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date -----------------------------------I--- <br /> Septic Tank (Specify Requirements) -------------- -------- --- - ------- ------- <br /> ------------ <br /> -- <br /> -- <br /> Disposal Field Specify Requirements <br /> -------- =--- <br /> - ------ . -•---•----------- <br /> �� �c� <br /> { --- ----- <br /> •�-.�...-. 4 -. <br /> ---------------------------------------------- -"____.-"_____________._____-__--_ _ "_____ _________-"_-__-___-M______________""_""______-_____________--____._-"""_-___-___-"____-_______ <br /> {Draw existing and required addition on reverse side) <br /> I hereby certify that I have iprepared 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: j <br /> "I certify that in the performpnce 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." I <br /> Signed ------ ----- <br /> Owner �.�. / K <br /> BY --- ----- � -------------------------------------- Title % - <br /> other than owner] <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED ------------------------------------------------------------------ DATE �� ��-------------- <br /> BUILDING PERMIT ISSUED --------------------- ----DATE ----------------------------------------- <br /> ADDITIONAL COMMENTS -------------- ------------------------------------------------------------- -- F. <br /> -----4,t----------------------------------------- -•- <br /> -------- -- -------------------- <br /> ---------------------------------------- -------- - ----- ------- - ----------------------------------------------------'------------------------------ - - - - -- <br /> Final Inspection by: --- --------------------------- ----------- -------Date -- ------------C3----t <br /> SAN JOAQUIN LOCAL HEALTHDISTRICT , <br /> E. H. 9 1-'fi8 Rev. 5M `� <br />