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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> Permit No- ---------- <br /> (Complete in Triplicate) <br /> Date Issued _5_-_22-_7o-------------------------------------_-_______ This Permit Expires 1-Year From Date Issued <br /> t <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 /> �f r� <br /> JOB ADDRESS/LOCATION --v�------------------:�`_ <br /> ---A--- -------------------------- <br /> - - '-------- -- - - ----------------------CENSUS TRACT --------------•----------- <br /> Owner's Name -------- - - -------------- -------------------------------- -- Phone <br /> j = -- -------- ---- ° <br /> Address ---------------- �_ city ------ ----- <br /> -- <br /> ---- <br /> Contractor's Name -___ ,lliirueQe__ -� -.. _ z__ .-.License # _ Phone ______________________________ <br /> Installation will serve: Residence ©Apartment House❑ Commercial:❑Trailer Court ;[ <br /> Motel ❑Other -------------------------------------------- <br /> Number of living units:--------r__ Number of bedrooms ___-___Garbage Grinder ------------ Lot Size ----���`-s ---__________---... <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 21� <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 sewer is available within 200 feet,} <br /> PACKAGE TREATMENT [ ] SEPTIC TANK:[ ] Size------------------------------------------------ Liquid Depth -------------------------- O I <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' <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 'Q No <br /> Water Table Depth ------------------------------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit K# --------=----------------------------------- Date _____--____-__------___-__----_-__} <br /> SepticTank (Specify Requirements) --------------------------------------------------------------------------------------------:------------------.--------------------------- <br /> Disposal Field (Specify Requirements) _0�- --.-_-.___-A&---`— <br /> e e <br /> s! { <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, I 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 �4 ------------------------- ------------ Title -C_D_ci,�.�-!�-mar-u.-'---------------- <br /> ----- ---- --- <br /> (If other than owner) <br /> FOR .DEPARTMENT USE ONLY } <br /> APPLICATION ACCEPTED BY _ _ �.c.�__ ____ ___ <br /> ------------------------------------------------------------ DATE --`-�F�------�� <br /> ---------------------------- <br /> BUILDINGPERMIT ISSUED ------------------------------------------------------------•.....----------------------..----..-_...-...DATE -------------------------------- .......... <br /> ADDITIONAL COMMENTS -------------------- ------------- - - --------------------- <br /> ---------------------------------------------------------------------- --------------------------- <br /> _ ----------------------------------------------------------- <br /> ----------------------------------------------------------------- ------- <br /> i <br /> --------------------------- --- -- -- ------------- <br /> -- <br /> Final Inspection by - <br /> . --------------- <br /> ---- ---- - -- -- -- ---- ----------- --------------------------------------------------------- <br /> ---- --- - -------------------------------------- Date r t: <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT -- <br /> E. H. 9 1-'68 Rev. 5M <br />