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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> Permit No: <br /> ------ - <br /> ----------------------------- --------------------- <br /> (Complete in Triplicate) ,�-�----------- <br /> Application <br /> y <br /> - ---------------------------------------- <br /> - <br /> _--------__-_----- ------- ---------------- This Permit Expires 1 Year From Date Issued 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 existin Rules and Regulations: <br /> / L n ��.. A� <br /> JOB ADDRESS/LOCATIO <br /> N <br /> .- (a -.-, ^---------- /Jh-G ��' �-----/Z-P- -----.CENSUS TRACT ----s- ------ <br /> Owner's Namef _ _ `��'''�-- C�c- �F------------- Phone <br /> Address ----------------- nom✓-------- ----------------- . City ----- ------------ <br /> ----------------------------------------------- ------ <br /> License #��5_-'��---lam- Phane �-`l •� l <br /> Contractor's Name --- i ---- ,iz G`r-�--------------------------- <br /> Installation will serve: Residence ❑ Apartment Nouse^❑ Commercial :❑Trailer Court <br /> Motel ❑Other -------------------------------------------- <br /> Number <br /> -------------------- --Number of living units------------- Number of bedrooms ------------Garbage Grinder ------------ Lot Size ---_--------------------------------------- <br /> Water Supply: Public System and name -------------------------------------------------------------- -----------.------------------------------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam X Clay Loam ❑ <br /> Hardpan ❑ Adobe'❑ 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.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ I SEPTIC TANK![ ] Size-------------------•---------------•---- --- Liquid Depth ----------------•--- ----- <br /> Ca acit - Type -------------------- Material---------------------- No. Compartments -------------•-------- O <br /> Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ---------------------- O y <br /> LEACHING LINE [ ] No. of Lines ------------------------ Length of each line---------------------------- Total Length --------------------------- -- <br /> 'D' Box ------------ Type Filter Material ---------------- <br /> -_-Depth Filter Material ------------------------------------•-.----- �1 <br /> Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line -----------------------. ; <br /> SEEPAGE PIT' F Depth --- Diameter ---------------- Number _--------- ------------------ Rock Filled Yes ❑ No .0 <br /> WaterTable Depth ------------------------------------------------Rock Size ----------------------------- -- <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line --------------.------- <br /> REPAIR/ADDITION{Prev. Sanitation Permit# -------------------------------------------- Date -----------------------•------••--) <br /> Septic Tank (Specify Requirements)-- -------------------------------------------- <br /> ------------------------ - -- --------------------------••---------_-.--------------- <br /> - -------------------------------------- ---------- - <br /> Disposal Field (Specify Requirements) ------- —/"2-5----------a --------v3----- ---------------•--------- ---- <br /> / --- <br /> - - ---------------------------- <br /> ----------------------------------------------------------- -------------- --------------------------------------------------------------------------- <br /> -------------------------------- <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that 1 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, I shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Y. <br /> Signed -----. • ------------------------------------ Owner <br /> By __ - -------------- Title ------------------------ ---------------- ------------------------------ <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY - - --------- DATE ------ <br /> BUILDING PERMIT .-------------------------------------------------------------------------- - = --- -- DATE <br /> k ADDITIONAL COMMENTSENTS ---------- ---------------- - -------- ------------- ---------- <br /> -------------------------------------------------- -V <br /> i ----------------------------------------------------------------------------------------------------- <br /> ----- --------------------------- <br /> � <br /> Fina! Inspection b Date --..--- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F H 9 1-'68 Rev. 5M <br />