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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> ICornplete in-Tr p icatelI <br /> ii <br /> ---- ----- - ------------ <br /> Dafie Issued <br /> lf <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 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 /> I JOB kADDRESS/LOCATION l CENSUS TRACT -------------- -------- <br /> er's Name ----- kz�----- Jc. �t -----------;-- -------------------------------- ' Phone -------------------- <br /> -S a' � =------ ------ ------------------------------------------------ CitY , -��=c�t <br /> ass --- --- - <br /> Contractor's Name -- _ s -�✓C 'C �-----------------------License #,�c _�?"--�_j17.-_ Phone - - - --1- ..� _ <br /> Installation will serve: Residence IV Apartment House❑ Commercial ❑Trailer Court ;❑ ; <br /> t <br /> 'Motel F-1 Other __- _ === <br /> ; - -L <br /> Number of living units:.... Number of bedrooms' __3----- Grinder _._----._.._ Lot Size - G �'� ----=--•-• <br /> Water Supply: Public System and name ----------------------- - ------------------------------------------------- -----------------------------Private <br /> Character of soil to a depth of 3 feet: ` SandSilt ;Clay ❑ Peat F-1 Sandy Loam ❑ lay Loam EJ' 13 <br /> J` <br /> Hard Fan []aye,Adobes❑ Fill Material ------------ If yes,!type ----------------'__�1V ----- <br /> (Plot plan, showing size of lot, location of systrn in relation to wells, buildings, etc. must be placed on rev�rse ,side.) <br /> NEW INSTALLATION: (No septic tank or seepage pitpermitted if public sewer is available within 20O feet, <br /> PACKAGE; TREATMENT [ ] SEPTIC TANK'[ ] ; >' Size--- -------------- <br /> Capacity <br /> ---------- --Ca acitY ------- TYpep MaterialNo. --"---'-.1.--'-.•.---.-•-------- <br /> O <br /> 6 <br /> iDistance to nearest: Well -------- -------------------Foundation ----f-.6------------- Prop. Line .._ ':_ ----- J <br /> 3 LEACHING LINE [ I No. of Lines ___ -----_._ ---- Length of each line-_ _ _______________ Total Len gth -----j_.� ____:_________. <br /> 'D' Box t4k-A --- Type Filf& Material ---r ----------Depth Filter 'Material -------' -Y----------------•------------ f�[ <br /> i <br /> Distance to nearest: Well __�-�=.___________ Foundation _-_ _--_ -------------- Property Line _-_J_________________ <br /> SEEPAGE PIT [ ] Depth Y-1-le---------- Diameter-�1'1_xj__O--- Number -------- -------------- Rock Filled Yes X No iC, . /1 <br /> i ] Water Table Depth -------- ---------------------------- ----------Rock Size -------------------------------- <br /> Distance <br /> ------------------------------Distance to nearest: Well ___ __ _____---------------------'-_.Foundation --------------------- Prop. Line ______--__ --------- � <br /> REPAIR/ADDITION(Prev. Sanitation Permit ` -._.__7.----- ----------'-- Date ----------------------------------} <br /> Septic Tank (Specify Requirements) '--------------------- --------------------------------------------------------------------I----------- -------------- <br /> Disposal Field (Specify Requirements) ------------------ <br /> r i <br /> ------------=------ <br /> -- -------- -- ------ --------- --- -- ------- --- c <br /> ------------- ------------------------ ---- -- ------- <br /> d ------- <br /> ---------------------------------------------------------------------- <br /> (Drag existing and required addition on reverse side} <br /> I hereby certify that 1 have preparecIA4 application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, State Laws, and Rules and Reguliations of the. San Joaquin Local Health District. Home owner or liven- <br /> ! sed agents signature certifies the following: <br /> r "I certify that in the performance of the work for which this permit is issued, I shall not employ any person lin such manner <br /> as to'become subject to Workman's Compensation laws of California." <br /> f k <br /> iSigne'd ---------------------------------------- -- ----------- --------------------- Owner <br /> 1 t <br /> By _.I�(�-> ---�- - ��--- ------------- -------'-------------------- Title -------------------- -------------------- ------------------ ---- <br /> (1f other than owr] # <br /> r FOR DEPARTMENT USE ONLY <br /> + APPL.ICATION ACCEPTED BY . ' '1 �-"` '"'' --------�,ft----------------------------------------- DATE --------�-- ----•-�� ---------- <br /> BUILDING PERMIT ISSUED ----------'----------- z -= ---------------------------------------DATE --------------------------------- <br /> ----------------------------------- <br /> ------------------------------------------------------- <br /> ADDITIONAL COMMENTS ------- -------------- --------------------------------------------- --------------------- <br /> --------------- - ------------------ ----------y�------------- ------------------------------------------- -----------------> <br /> I ► s. i ------------------------------- <br /> ------- --- ------------- -------------------=---------------------------------------------------------------/------------- -------------------------- -------- <br /> rx <br /> FEnal'Inspection by: ------------ - ---------------------------------------- --------------------------------Date ---- -------------- -. -=s.-------- <br /> r { SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M - <br />