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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> --------------------------=---------- - <br />` (Complete in Triplicate) Permit No. _._T-3--------___-_ <br /> --------------------------------------------------------- This Permit Expires t Year From Date Issued <br /> 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 /> ff - <br /> JOB ADDRESS/LOCATION ._ ./__.�r� __._, -.--- -- -------h ----------CENSUS TRACT - -•----------- <br /> Owner's Name _- �'�� `° --•Z7 ------------------ �" Phone <br /> -- <br /> Address --`-- ---------=---------------------------------------------•--. city-__ - �L�-------------------------,-p----------••---------. <br /> Contractor's Name `*-- - --�------------------------ ic�rfse ►' Phone .t1._ --------------- <br /> -------------------------------- <br /> Installation <br /> .5� <br /> Installation will serve: Residence's Apartment House❑ Commercial ❑Trailer Court ,❑ <br /> Motel ❑Other --------------- ---------------------------- <br /> Number of living units_____________ Number of bedrooms -- g_ -_:Gdrbage 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 ❑ 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'sew.e�is available within 200 feet,) <br /> PACKAGE TREATMENT t - " " "' 1 <br /> [ SEPTIC TANK'[ ] Size--- ------ Liquid Depth-"--- --�-----------.----- �p <br /> Capacity -------------------- Type -------------------- Material----------- ---------- No. Compartments ---------------------- <br /> Distance to nearest: We.ll ----------------------- -y -_------Foundation ---------------------- prop. Line ---------------------- <br /> - <br /> LEACHING LINE [ ] No. of Lines _____________----------- Length of each line---------------------------- Total Lengt� ----------- <br /> -___________.____ <br /> 'D'.Box ------------ Type Filter.Material --------------------Depth Filter Material .........-:-------------------------------- <br /> Distance <br /> -_____ ____ _ _Distance to nearest: Well ------------------------ Foundation ----------------------------Property Line _'_ ._______---_--_. <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter --------------- Number _______._._____.________ Rock Filled Yes ❑ No I❑ <br /> Rock Size <br /> —Z'5-�\.� , <br /> Water Table Depth ----------- ----------------------- A <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ------ -------•-•--•-- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# _______. ----------------------------------- {'�--�__ R___�__`--- �" J� <br /> Date ---- <br /> Septic Tank (Specify Requirements) ---=----------=------------------------<-•-_--------------- <br /> Dis osal Field Specify ___ ___ _`_ _-� ----- _ ___________ <br /> t <br /> ------ ------------------------------------ -------------' <br /> Ali <br /> j, zr <br /> (Draw existing and required addition on reverse side) <br /> I 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 andfRegulations 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 cmV-person in such manner <br /> as to become s blect to Workman's C pensati.on Upes at ifornia." <br /> Signed-- Owner <br /> /1 � <br /> BY -- -- --------------------------------------------------- 1----------- - ------ -------------- Title --------------- + <br /> (If other Phan owner) <br /> FO .DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTE BY - DATA: ----------------- <br /> BUILDING PERMIT ISSUED ---------------------------h-4 <br /> DATE = <br /> ADDITIONALCOMMENTS - -------------------- -------------•- --------------------•--•----------------------------------------------------------------- <br /> _.. -- _ <br /> - ---------- -- - - ----------- ------- -------------- - --------------- --------------•-------------------------- I <br /> - _ �_ ;% _ <br /> ------- ----- _:- --_.-- _ - _ , <br /> Final Inspection b ------------ - -----------------------------------------\ ":__lam_ <br /> P Y� ---- ------`---�:r-f�.. - ----------------Date <br /> - - �-- - J- ---._------ � <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'b8 Rev. 5M <br />