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r <br /> ' 7 <br /> FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> Permit No: <br /> (Complete in Triplicate) <br /> his Permit Expires I Year From Date Issued Date Issued .......z` <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 Mules and Regulations.. <br /> JOB ADDRESS/LOCATION --------- 7 ----- - -- -- ----- - -- --- - -------- ---CENSUS TRACT -------------- -j----------- <br /> Owner's Name ------------- --------5. = -------- --- ---- <br /> [.------- --- --------- ---Phone ------ <br /> Address ----------------- -a= -- - -------- -------- City ------ - --- - ---- ----------C-�---``--`----------------------- <br /> Contractor's Name F � License #l0fl�//------- Phone <br /> Installation will serve: ResidenceApartment House❑ Commercial :❑Trailer Court ;❑ <br /> g ❑ ------------- -------------------- --•--- / <br /> Number of living units:--- Number of bedrooms°____________ Q <br /> Motel Other _ <br /> Garbage Grinder ------------ Lot Size �---- -1-- ------------------ <br /> Water Supply: Public System and name ------------=------ - -------------------------------------------------------------------...-----Private` <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ 'Clay F] Peat E] Sandy Loam ❑ Clay Loam "[] / . <br /> Hardpan ❑ , Adobe-7j,_ Fill Material ------------ If yes,type --------______________-__- <br /> (PI'ot 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 [ ] SEPTIC TANK [ ] Size------------------------------------------------- Liquid. Depth -------------------------_ <br /> Capacity ----------- --------- Type -------------------- Material------ --------- No. Compartments <br /> Distance to nearest: Weil -------------_----------------------Foundation ----------------------- Prop. Line -__-_-_----_._...__._. <br /> LEACHING LINE [ ]. No. of Lines - -------------- Length of each line----------------------------- Total Length _________._-____-__ ........ <br /> k 'D' Box .--.-------- Type Filter Material --------------------Depth Filter Material __.------------.---------------.-----------. <br /> Distance to nearest: Well ------------------------ Foundation ---------- .............. Property Line <br /> SEEPAGE PIT [ ] Depth __.__-------------- Number ---------------------------- Rock Filled Yes ❑ No C3 <br /> WaterTable Depth --------------------------- --------------------Rock Size -------------------------------- <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line -__-.-_----- _._____-- <br /> REPAIR/ADDITION(Prev. Sanitation Permit r# -------------------------------------------- Date ----- ...-----------------------) <br /> Septic Tank (Specify Requirements) ----------------------------------- ---- -----------------------------t} - - •---------------------------- <br /> Disposal Field (Specify Requirements) ---------- - -K x =�'v------. ----Q �--- ------------ ------•----------- <br /> Q ----- - - - ------------------------------------- <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_Regulotions 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 i4drk,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 /> Signed --------------- ------------- ----- -- - - Owner V <br /> �`�'V ------ 4---- - 7i#le ' <br /> BY - = ----------- <br /> (If other n owner) <br /> i, <br /> FOR DEPARTMENT USE ONLY ` <br /> APPLICATION ACCEPTED BY ----- ------------------------- -- ----------------------------------------- --- ----- DATE -_1© LO_1'�a---------------- <br /> BUILDING PERMIT ISSUED ------- --- ---------------------- ----------- ------------------------------------------------------DATE --------------------- --------------------- <br /> ADDITIONALCOMMENTS- - ---------------------------------------------------------•------_---------------------------------.----------------------------- --------------------------- <br /> - - - - - <br /> - -- - ---- ------- <br /> -------------------------------------------------------------------------------------------------------------------------- ------------------------ <br /> - - ---- - --- <br /> ---------= _ ------------------------= ---------W { j <br /> --------------------- ---------------------------------==--------- ----- <br /> Final Inspection by: --- ----- --------- ------------------------------------------------------------- -------------------------------Date ---------F -4 ----------_------- <br /> '------------------- <br /> 'SAN JOAQUIN `LOCAL.HEALTH DISTRICT <br /> F. H. 9 1-'68 Rev. 5M <br />