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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT f <br /> -------"---- »� `�'� j - p P �1 dzfo <br /> 1,I fit, (Complete in Triplicate) Permit No. --------------------- <br /> -------------- <br /> _ - -.------ - <br /> -----------;-icy-- - '------------------------------- � <br /> -------__ This Permit Expires 1 Year From Date-19-stied) <br /> Date Issued <br /> Application is hereby made to the San oaquin Local Health District for alpermit to construct and install the Work herein <br /> described, This application is made in compliance withiCounty Ordinance No. 549 'and existing Rules and Regulations. <br /> J. <br /> _ ------CENSUS TRACT -- (--------------------- <br /> JOB ADDRESS/LOCATI/O�N . _ _ _ , _ "l_____ ,, --------------- <br /> Owner's Name -------lam-o __. - - ---------- --Phone-------------------------------------- <br /> ----------------- <br /> ------- ----- --------------------- <br /> t -- --- ------ <br /> Address -------- ----- tY ----------- ------------------- <br /> Contractor's Name ._---- .- --�` - �f� -- -` -------------------------------License #1 40 Phone <br /> Installation will serve: ResidenceXApartm House❑ Commercial ❑Trailer Court i❑ <br /> Motel ❑ Other -----------------------------------I--------- <br /> r � <br /> Number of living units:__. ----- Number ofbedrooms _ -__-Garbage Grinder/l/47--- Lot Size . - -- - -- - - --_.... <br /> Water, Sup U1. Public15ystem�and name ---C,a. �- - �t -sie .1-------------•--------------._Private ❑ <br /> Character of soil to a depth of 3 feet: Sand ❑ Silto Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Ha.rdpan E] A& e Fill Material ------------ If yes, type ---------------------------- <br /> (Plot plan, showing if s ze o lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> 111 <br /> NEW INSTALLATION: /"'{No septic tank or seepage pit permitted if public sewer is available within 200 feet,} <br /> PACKAGE TREATMENT,, [ Ij SEPTIC TANK'[ ] Size------------------------------------------------ Liquid Depth -------------------- <br /> Capacity -------------------- Type ----- <br /> ----------_._.--.--Ca acit ------ Material-- --_ - - --_ . _ No. Compartments .................:....J= <br /> 1 � Distance to nearest: Well _ ------------------------Foundation ---------------------- Prop. Line -------------_-_._.... <br /> LEACHING LINE [ ] No. of Lines Type Length of each line____.___ _ _ _ _ <br /> __ ,_ - -.---- Total Length --------------------------- <br /> D <br /> YP Filter Material --------------------Depth Filter Material --------------------------------------- <br /> Distance <br /> -----------------------=-------------Distance to nearest: Well -------- -------------- Foundation ------------------------ Property Line, --------------- 'yam <br /> L 1 P ----- ------------- --Diameter . ---------------.Number. ---------------------- ---- Rock Filled Yes ❑ No <br /> SEEPAGE PIT Depth R <br /> t ! <br /> Water Table Depth ------------------------------•---- ----------.-Rock Size -------------------------------- <br /> Distance to nearest: Well ------------------------------------ ...Foundation r-------------------- Prop. Line _------------------- <br /> REPAIR/ADDITION <br /> _ ----.__-------REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date -__-_- _---.----__--------------} <br /> � i <br /> r. Septic Tank (Specify Requirements) -------------- � --- ------------- -- ----------------------------------------------- ------------------------­ <br /> P` . <br /> ,�tDisposal Field (Specify Re�ements) ---zllp i-_------ ---_� --. �f __ --- ------- <br /> A .---✓ - ----------------------------------------------------------------------- --------------- : <br /> -- - ----------- ---- ---------------------------------- -----------------------------------------------=-------------------------------------------------------------------------------------------- <br /> f (Draw existing and required addition on reverse side) <br /> I hereby certify that I have prepared Ithis 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 Compensate laws of California." <br /> Signed ---------------------- ------ Owner <br /> BY ------------------------------------ - ---------- ------------------- Title ........ ---------------------------------- <br /> (If other an owner) <br /> FOR DEPARTMENT USE ONLY <br />{ APPLICATION ACCEPTED BY --C---- DATE '^ ------ ------------------- <br /> - --- --- ------------------------ <br /> BUILDING PERMIT ISSUED - ------- DATE <br /> - -- ----------------------------- -- --- --- ------ <br /> ADDITIONALCOMMENTS ----- ------ - - -------------------- ------------------------------------------------- r`-------- ------------------------------------------------ <br /> ------ <br /> Final Inspection b �_ <br /> P Y° - -------- Date �-- - <br /> SA JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 ]° '68 Rev. 5M. <br />