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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> � ----- &, OW-------------------- Permit No. <br /> �. (Complete in Triplicate) <br /> ---- -- ------------------- ---------------------------" <br /> Date Issued Y- <br /> - <br /> _ <br /> --_---_---------------------------------__------_.__. This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a permit to constr-uct.and.install -thp_w9rk.,herein <br /> described. This application is made in c omplian 'th County Ordin nee No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS LOCATION..---- ='^r .---<---------------CENSUS TRACT _-_---------------._------ <br /> Owner's Name �? Phone <br /> ----------------- - <br /> Address ------------------ - = ---- -- - -- --- �= CitY ------------ -------�f -- <br /> Contractor's Name -- ---------- - ----.License<# ------- -.-------------- Phone -X_ . <br /> Installation will serve. Residence ❑ Apartment House❑ Commercial -]Trailer Court i❑ <br /> i Motel ❑ Other -.+-------------- - - - - - --- <br /> Number of living units:___ ----- Number of bedrooms' ---' <br /> ar age ri er ___ .v----- Lot Size ---_/_i✓J__l`�_a- <br /> - -_-' <br /> - <br /> Water Supply: Public System and name --------------------"�=----- - - ------ - -- --- ---- --------------------- -- ---_-_Private ❑ <br /> Character of soil to a depth of 3 feet: Sand'[] Silt❑ CI6 E] ea ` .5dndy Loam .❑ Clay Loam ❑ <br /> Hardpan ❑ AdobeFill 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 [ ] aSize---------- -----------------------------l------- Liquid .Depth -------------------------- \ <br /> I <br /> Capacity ----- -- ----------- Typey Mat rias No. Compartments ...................... <br /> Distance to nearest: Well ------------------------------------Foundation -----------------------.Prop. Line -----•----- <br /> I-L <br /> LEACHING LINE [ ] -No. of Lines ------------------- Length of each line--- -- ------ ----- Total length ------ --------------------- <br /> 'D' Box ------------ Type Filter Material --------------------Depth 'Filter Material --------------------.-------------------:--- <br />''d Distance to nearest: Well '-- --- -------------- Foundation-- __-- --------- Property Line ------------ ----------- <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number ----------------------------- Rock Filled Yes ❑ No .i❑ <br /> :Water-Table Depth-----------=---- -----, <: -----------------Rock Size ------------------------ ------- <br /> Distance to nearest: Well --------------------------------- ------Foundation A----------------- Prop. Line ------­--------_---- <br /> REPAIR/ADDITION(Prev. <br /> ------ --------_---- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ----------------------------------------I--- Date --------------J---------_....-___-) <br /> 5e tic Tank (Specify Requirementsl -------- ------------------ --- --- - ---------� ----,- -----.., --�----- -----:--- -----------�-�---- <br /> -------------- <br /> p P Y '`� p <br /> ~ i '+� ~ �J�.l <br /> Disposal Field (Specify Requirements) ---- -- -- ---- r f <br /> fk,, t <br /> y' x is <br /> --------------------------------------- --------- .`'I - ------- - ------------------------ <br /> ----------------- <br /> --- ---- --- - <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 /> j 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 /> i <br /> Signed ----------- -------- --- ------------------- --------------------- Owner <br /> - - ----------------------- Title . ---------- ---- - ------- ---------------------------- <br /> BY ------------------ = <br /> (If other t owner]--- ---•-�-• --� -Y--�-�-- <br />' , —FOR DEPARTMENT USE ONLY <br /> j APPLICATION ACCEPTED BY 1J: `-- ---- -----------------------------. DATE __J/°�z -k c� <br /> l <br /> BUILDING PERMIT ISSUED ------------------------ " ' '"" '' "` ` "' <br /> ADDITIONAL COMMENTS ---------- ---- �" � - _ - _ <br /> -------------------------------------- -------------- �g <br /> - -��---------------------------- - - ---=- <br /> ------------------------------.-------------------_----------------------- r------ <br /> ------ <br /> ------------------------------------------------------- ----- - -- <br /> I Final Inspection by L � -------� <br /> ------•----------------------------------------Date ---- ----Jr- <br />[ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. SM <br />