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FOIA OFFICE USE- <br /> ................... .......... <br /> SE: <br /> ........:......................:................... <br /> APPLICATION FOR SANITATION PRRMIT <br /> No Permit N ....... . <br /> (Complete in Triplicate) SS j <br /> b• This Permit Expires f Year from Date Issued <br /> Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construe# and Install the wont herein <br /> described. This application is made in compliance with County Ordinance No. 5.49 and existing Rules and Regulations- <br /> ei l <br /> JOB ADDRESS/LOCATION .... . ._ . ..�s1�. . � .............................................CENSUS TRACT .......................... <br /> Owner's Nameoe— <br /> ! Q <br /> - -- - -- - •----.. -- -- ..:..---l:y �•-*...............:....:.:..............Phone ....._........-•---.............---- <br /> Address --------------- e ..city .............I.........I..................................................... . <br /> Contractor's Name _.... License �1 9P 1` ' -- one <br /> Installation will serve: Residence 0 Apartment Nouse�] Commercial�[ra e <br /> r Court EJ <br /> Motel ❑Other---- � ...........:...... <br /> Number of living units:-............ Number of bedrooms ------------Garbage Grinder ............ Lat Size ............................................ <br /> Water.Supply: Public System_ and name ............. r� <br /> ---•--• . ..-- -------_..... <br /> Character of soil to a depth of 3 feet• Sand[) ❑ .-•........ Private.... ate <br /> Silo Gay ❑ Peat p Sandy Laam Gay Loam <br /> Hardpan p Adobe 0 Fill Material <br /> • � ............ If yes,type. <br /> (Plot plan, showing size of lot, location of system in relation for walls, buildings, etc, must be placed on reverse side.) , <br /> NEW INSTALLATION: <br /> INo septic tank or seepage pit permitted If public sewer is available within 200 feet,) �. <br /> PACKAGE TREATMENT ( j SEPTIC TANK{ ] Size....................................... Liquid... <br /> Depth .----.................... <br /> Capacity _....--•---._. • . <br /> .,- Type •-----••------••---- Material.------•------------- No. Compartments <br /> ...................... <br /> Distance.to nearest: Well -,----•.............................Foundation _..._.._ ............. Prop kine ...................... <br /> LEACHING LINE i j No. of Lines _.._..... .... Length of each line.......... ---.. Total Length :..�z ............... <br /> D' Box ' Type filter Material ......Depth .Filter Material <br /> 1 <br /> Distance to/nearest: Well -----------------_---_ Foundation ...............•._.;..Property Line ........................ <br /> SEEPAGE PIT I 1 Depth �t Diameter ..........:..... Number ... ..................Rock Filled Yes� No <br /> Water Fable Depth -•-•------------------------------- <br /> ­-----------Rock Sizery.___1 <br /> -- <br /> Distance toInearest: Well --------------•.-•--.-----.........._...Founda#ion ---•• -..... <br /> ........... <br /> _. <br /> ProP. tine ...................... <br /> REPAIR/ADDLTiON(Prev. SanitationPermit ..:..._ pate __.........:........ <br /> - ............ <br /> Septic Tank (Specify Requirements) ---------------- <br /> - ---•..................................�..._........ .................._................. <br /> Disposal Field (Specify Requirements) -------------• ........................................................_...:.--•--••---•••-- <br /> _-- <br /> ---••--------------- --•------- -------------.... I------------ -- <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 dare in accordance with Son 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, 1 shelf not.emiri+ry any parson In such manner <br /> as to become subject to Workman's"Compensation laws of California.,, <br /> Signed ------ Owner <br /> BY ...-•---- - Title .........:...-------------------- <br /> I <br /> f other t�ano )er)" <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED [iY ---- -- = DATE a '�� <br /> BUILDING PERMIT ISSUED --- ----- .............. :._.. DATE <br /> ADDITIONAL COMMENTS -------------------------..-..._.......... - G. <br /> -------------•----------------• ------- --------------- --------------•-- ----------------------------------------------- <br /> --- --- <br /> ..- ...-- ... _. ........ --•---•--------•-•----...-----•-------_-._.......... ............................ ... .. <br /> FinalInspection by: .. 1 ----------------------------------------------------------------------------------Date -. ---- ..e�..---`....... <br /> EH 13 2h 1-68 v. 5M I SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M <br />