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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> Permit No. <br /> --------------------------------------------------------- <br /> (Complete in Triplicate) <br /> F ____________________ ,This Permit Expires 1! Year From Date Issued Date Issued -7/ <br /> ------------------------------------------- <br /> Application is hereby made to the San Joaquin Local Health District for a per to construct and install the work herein <br /> described. This application is made in compliance with County Ordinance No. 5.49 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION . A._-�-- -- -------- <br /> CENSUS TRACT _s�`C---------- <br /> Owner's Name ----141 _ - �� -------------- - --------------------------------------------- ----------- <br /> -----._Phone ------------------------------------ <br /> Address ------ r--o V� <br /> - - --- -------=----------------------- <br /> --------------- <br /> ------- CitY <br /> Contractor's Name - ---------.License # ------------------------ Phone ------------------•----------- <br /> "" <br /> Installation will serve: Residence] Apartment House°❑ Commercial []Trailer Court i❑ <br /> pp Motel ❑ •_ <br /> Other ------------------------------------------ <br /> Number of living units:---L_------ Number of bedrooms _-__.-3----Garbage Grinder ------------ Lot Size _ _11 ------ ------ <br /> Water Supply: Public System and name -------------------------------•---- -----------------•----------------- -------------------------------------Private.0 <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ ' Clay ❑ Peat❑ Sandy Loam -❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe-E] 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.) W <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> r <br /> PACKAGE TREATMENT f I SEPTIC TANK:ft Size-j-1_/A- '---. -------------- Liquid Depth _.It�-----------.-____. <br /> Capacity,A.Qz------- Type -cl.^�__ Material_--__- No. Compartments ._____-•.-..._-- <br /> Distance to nearest: -Well __- 4� "i�'___________________Foundation __-- -------- Prop. Line .__ +___*'--------- <br /> LEACHING LINE �J No. of Lines _3 ________ Length of each line ------------------ Total Length ___*�'-- ---------------- <br /> 'D' Box _ _,vim_ Type Filter Material _ _-________Depth Filter Material <br /> _11-4------ --------_------------ <br /> Distance to nearest: Well _ f7--�_f-------- Foundation _44' <br /> -4 Property Line .�_�*_____________ <br /> __ Number ___.__.__ ____ Rock Filled Yes)`IP No 0 <br /> SEEPAGE PIT f�-] Depth _. - �- - Diameter 3 ---- ,G� <br /> Water Table Depth l- O---------------------------------------Rock Size <br /> Distance to nearest: Well _. ___------------------------Foundation ---/_aQ`_______ Prop. Line _1_ '___._.-.--__ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ------------------------------------------- Date -----------------------------.----) <br /> Septic Tank (Specify Requirements) - ---•------------------- ---------------- ------------------------------------- ------ <br /> DisposalField (Specify Requirements) ---------------------------- -•-------------------------------------------------------------------------------------------------- - <br /> ----------------------- ------------- ---------`--------------------------------- ----------•---------------------------------------------------------------------------------- <br /> (Draw existing and required addition on reverse side) <br /> 1 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, 1 shall not employ any person in such manner <br /> as to be�c/omejubject t Workma omp sation laws of California." <br /> Signed -7/' C.a. 'W------------------------------ Owner <br /> By __:------------------------- ------------------------------------------------------------------------ Title - -------- --- ---------------------------------------------- <br /> (If other than owner) <br /> FOR .DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -__. DATE lea____-,�_ �'),L.__-.________.--_ <br /> BUILDING PERMIT ISSUED ----- --------------------------------------------------------------------------------------------------DATE ------------- -•---- <br /> ADDITIONAL COMMENTS ---.----------------------------------------------------------------- ---------------------;------------------- - ---- <br /> - <br /> -------- <br /> ----------- -------- ---------------- ---- ------ - ----- <br /> - -- ----------- --------- y <br /> =: <br /> y <br /> ------------------------------------------------------ ------------------------------------------------------------- <br /> FinalInspection by: -- --------------------------------------------------------------•------------------ ---------------------------------Date --------------------- --- ----- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'b8 Rev. 5M - �+ <br />