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FOR OFFICE USE: . �- � y <br /> APPLICATION FOR SANITATION PERMIT <br /> ----------------------------------•-.--------------- -_ - 71 �6y <br /> (Complete in Triplicate) Permit Na. ______-~_----_ _--- <br /> _______________________________________ ----------- �. This Permit Expires 1 Year From Date Issued <br /> Date Issued -77+_2.7 <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 m din con3plionce with unty Ordina ce No. 549 and existing Rules and Regulations: <br /> �P 4 <br /> JOB ADDRESS/LOCATIO - -------- - ------o.----.- -- " ----CENSUS ACT -----------------•- -- <br /> Owner's Name ----------------------- ---=- -- ---- - _-Phone ------------ ----------------------- <br /> Address ------- - / - - ---- City-- --� ----- ------ - ---------------•-----• • - --- -------------------•-----•----------------•--------- <br /> Contractor's Name ----- --- ---- - ---- ----- --- - ------= ------- -------------------Lice nse # _1d131F Phone -----•---------------•-------- <br /> Installation will serve: Residence Apartment House❑ Commercial ❑Trailer Court ;❑ <br /> i <br /> Motel ❑ Other ------------------------------------------- <br /> Number of living units:----I------- Number of bedrooms -3------Garbage Grinder ------------ Lot Size .- __._____:' ------ <br /> r • <br /> Water Supply: Public System and name ---------------------- ------------------------------------------------••------------•-----------------------Private [ <br /> Character of soil to a depth of 3 feet: Sand 0 <br /> 1t Silt❑ Clay ❑ Peat❑ Sandy Loam .0 Clay Loam ❑ <br /> A' Hardpan ® Adobe '❑ Fill Material ------------ If yes,type ---------------------------- <br /> (PIoti�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'[ <br /> -_ Size. _ � Liquid <br /> Depth ----tt___--_-_-___--___ <br /> No. Compartments _ .:__.. �OCa acitY TYpe� �* �___ Material _ <br /> Distance ` <br /> to nearest: Well --_--_------Z__�_..__._...___Foundation --_1-P_r......_. Prop. Line ... ......_.... <br /> LEACHING LINE � No. of Lines ---_- ------------- Length of each line---.4_'i'_- --._----.-._ Total Length :..___L_—b__.�______ <br /> 1 'D' Box ..;.�------ Type riper Material ____ ,_____Depth Filter;„Material ______��►------------------------------ <br /> Distance <br /> --- --------•-•--_-. --.-Distance to nearest: Well --------4----------- Foundation ----t•e?------------------ Property Line, 5................ <br /> SEEPAGE PIT [ Depth ---_-__ __.__ .. Diameter __. _________ Number .----..____________________ Rock Filled Yes E# No C] <br /> Water Tablle Depth -------------- �?d-----__ `� ` r <br /> Rock Size �--------------_------- <br /> ------------ <br /> Distance <br /> -X=4 .... <br /> 4 I � ' _ � r -� - i � r <br /> - Distance to nearest: Well -.-----_-_--� 0.a----____________Foundation -___ -`I__C3---_--_ Prop. Line _--_-_�-__-_-••-•_ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ___'---------------------'-j_-__---`_-___ Date --_-_-:- ___-_ --- -� -- ).: <br /> Septic Tank (Specify Requirements) ----------------------------- ------=----------- -------------------------- ---------- Y <br /> Disposal Field (Specify Requirements) ---------------------------------------------------------------------------------------------------------------------•-- ----------- <br /> r _ <br /> -------------------------------------------------------- ------------------------------------- t <br /> (Draw existing and required addition on reverse side) <br /> Thereby 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 liven- <br /> sed agents signature certifies the Following: <br /> "I certify that in the performanc a work for which this permit is issued, I shall not employ any person in such manner <br /> as to'become subject to Wo ma mpensatio a of California.” <br /> Signed ------------------------------ ----- ----- - -- ------ --- --•---- -------------- Own <br /> . ----- - <br /> By -- - ` -- Title --- - -- --- C� <br /> ------. <br /> o <br /> (If other than own <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BYI .-e _ '------------------------------------------- - ------------------. DATE r�� 7� J� <br /> BUILDINGPERMIT ISSUED ------------I--------- - - --------------------------------------------------------------DATE ------------------------------------------ <br /> - - ------------- - <br /> ADDITIONALCOMMENTS -------------I------------------- -------------------------------------------- ------------ ------------------------------------- ----------•---------------- <br /> - ------ -- -------- - -- - ------- -- <br /> ------------- ----------------- --------------------------------------------------------------------------------•--- <br /> -- ----- <br /> --------------- <br /> Final Inspection by: - ---_--Date --. _ _`.�_cZr ` <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'6$ Rev. 5M <br />