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FGA OEFIE USE: x APPLICATION FOR SANITATION PERMIT _ <br /> 6 <br /> 9��� <br /> -- ..----- 'r�:�-- /------ �` Permit No. - -- - --� <br /> (Complete in Triplicate) <br /> ---------------_-__-_ --------__-- This Permit Expires 1 Year From Date Issued Date Issued <br /> . ti : �: � <br /> Applicaon is hereby m' ade; 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 /> ( '.......CENSUS TRACT -------------------- <br /> JOB ADDRESS/LOCATI N F_-- _- . __ 1 -- <br /> Owner's Name �I Phone <br /> Address --- -------------------- --------- City -------------------------------------------- <br /> Contractor's Name -------------------r�rt t,Q► i----4t ---------------License # �L�'D ��-------- Phone <br /> Installation will serve: Residence ❑ Apartment House,0 Commercial :❑Trailer Court i,❑ <br /> s I x 4� ' <br /> I Motel ❑ Other ------ ------------------------------ - <br /> If <br /> Number of living units:----- Number of bedrooms -_�- _Garbage Grinder __________ Lot Size _`!Rt___JK--- -- -----------•----- <br /> i <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 ❑ AdobeFill 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 /> Z <br /> NEW INSTALLATION: {No septic tank or seepage pit permitted if public sewer is available within 200 feet,} <br /> PACKAGE TREATMENT [ ] SEPTICTANK'bd <br /> Siz�e�e--- �'� -,----- No. ComdarDepth tments S�"--.---_-_-� <br /> Capacity ��---------�ITYpe --� ------------ Material �� �Compartments <br /> Line --------{� <br /> . <br /> t <br /> Distance to nearest: Well ____________________________________Foundation ____.___ --- p. <br /> LEACHING LINE � No. of Lines Type Filter Material a�elineDepth�lter Matenafa�__E1drh_______�o________________ , <br /> Type <br /> 'D' Box __ <br /> Distance to nearest: Well _____------------------- Foundation - ' Rock Filled Yes No .0 <br /> -----��------------ Property Line ---- --•- - <br /> i <br /> SE I7 [ ] Depth /_e�;(4_;�►�'iDiameter ____________-- Number --- ------------------ -- ' <br /> Water Table Depth ------------------------------------------------Rock Size ---------------- --------------- <br /> ' 0'` 4 ,ed Distance to nearest: Well --------------------------------------- Foundation ------4l'?- -_.__ Prop. Line __-�.. ____-__-- <br /> I <br /> REPAIR/ADDITION(Prev. Sanitation Permit# --------------------------------------------- Date -----------------------_----------} <br /> fi <br /> SepticTank (Specify Requirements) ----------------- -------------------------------------- --------------------------------------------------------------- --------------------- <br /> Disposal <br /> ----_Disposal Field (Specify Requirements) ------------------------------------------------------------------------------------------------------------------------------------- <br /> -------- ------------------------------------------------------------_-- ------------------- <br /> k _ _______________________________________________________ <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 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 /> Signed --------------------------------- -------- Owner <br /> �.... --------------- <br /> -- Title --------- <br /> (If other t owner) <br /> I OR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ----------------------- -- -- DATE IZ-._ Zy­7Q---------------- <br /> BUILDING PERMIT ISSUED -------------- ----------------------------------------------------- ----------------------------------DATE --------------------------------- --------- <br /> ADDITIONALCOMMENTS l• -- -------------------------------- ----------------------------------------------------------------------------------------------- -------- -•---------------- <br /> I <br /> - ----------------------------------------------------------------------------------------------------------------------------------------------------------------- -------------- <br /> -------------------- ------------ 1 - --------------- <br /> Final Inspection by: t F'�' 'l/ —'------ - ------------------ ---------------------------Date -,���7- ------� ------- ------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'6B Rev. 5M <br />