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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> ------- ------------------ ----------------------------- Permit No: --- ,= �3 <br /> (Complete in Triplicate) <br /> ---------I------------------------------ -------------- k <br /> �� Date Issued __._�_`__�_:-�,/ { <br /> -- ---------------------------------------------------J This Permit Expires II Year From 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 /> CENSUS TRACT ----:-----=' ---------.. <br /> JOB ,ADDRESS/LOCATION .------- ------ - ---x"'"1'1--._: -.._.._-.- .. <br /> Owner's Name ! '� Ql Phon [ ��La .� <br /> i- ---------------------------- ---- - - <br /> --------- -- ------- <br /> e <br /> Address - --------------- - Q _°_ . J '--s `:------------------------_- city -- 40.P/------------------------------------------------------------- <br /> �] <br /> Contractor's Name.---- 1 / iQ /f __ ':•S�!lO. ----------------•----------License # f00.4_11-------- Phone ----------._•----------------- <br /> Installation will serve-J , Residence XApartment,House�❑ Commercial:mTrailer Court '❑ <br /> Motel ❑ Other -------------------------------------------- <br /> Number of living units------!_---- Number of bedrooms ----3-_.Garbage Grinder - ---------- Lot Size _./CAD_. _L. d---------------- ..': <br /> Water Supply: Public System and name ----------------------•----:=----------------------------------------------------------------------------------Private <br /> Character of soil to a depth of 3 feet: Sand'[) Silt s Clay ❑ Peat❑ Sandy Loam Clay Loam ❑ <br /> Hardpan ❑ Adobe-C] Fill Material --------- If yes,type -----_______________________ <br /> buildings, etc. must be laced on reverse side.) <br /> (Plot plan, showing size of lot, location of system in relation to wells, g , p <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> ac y <br /> PACKAGE TREATMENT TANK'[ ] Size_____________________ ------------------------ Liquid Depth _____---_________..._,____. � I <br /> Capacity ... -------------- Type. ='------------------- Material-----`"---- -------- No. Compartments -----------_--------- <br /> Distance to nearest: Well ___________________________________Foundation ---------------------- Prop. Line -----------..:.______- <br /> LEACHING LINE { ] No. of Lines __________` ------------Length of-each line---------------------------- Total Length ----------- ---------------- <br /> 'D' Box --------: -,Type Filter Material---------------------Depth Filter Material ----------•_------------------------------ <br /> Distance to nearest: Well --------------- Foundation -------________________ Property Line ----- -------- ...... <br /> SEEPAGE PIT { ] Depth --------------_____ Diameter "_� __.'______,_,Number ----------------------------- Rock Filled Yes ❑ No ❑ <br /> Water Table Depth ------------------------------------------------Rock Size ---- <br /> ---------------------------- <br /> Distance <br /> -- `Distance to nearest: Well ---------------------—— ------------Foundation -------------------- Prop. Line -------------------- <br /> REPAIR,/ADDITION(Prev. Sanitation Permit# ---- __ —•_---- Date -_ ____-_-n_-_n_______--_.--------) <br /> 1 +r► I K <br /> Septic Tank (Specify Requirements) ------- <br /> 1't.. <br /> Disposal Field (Specify Requirements) ,---- - _ -=' <br /> ----------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------- <br /> ------------ ------ -------------------------------- ------------------- ------------------------•------------------------------------------------------------------------ ---------------- <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 /> B ` - Title ...... - ��__ •----------------------------------------------- <br /> Y ---------------- <br /> (If other a owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ------- "4---=---------------------------------- --------------------- DATE ------------------- <br /> BUILDINGPERMIT ISSUED ----- ------------------------------------------ --------------- --------- -------------------------------DATE ------------------------------------------- <br /> ADDITIONAL COMMENTS ---------- =` <br /> - ------- ------------------------------------------------------------ ----------------------- - -------------------------------------- -------------------------------------------- <br /> ---------------------- ---- <br /> l - <br /> ------------------------------------- - ----------------------------------------------------------------- <br /> Final Inspection by-. Date -- --J-- l ]�----- ---- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />