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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> '----- ----- ----------------------------------- <br /> (Complete in Triplicate) Permit o. <br /> -------------------------- This Permit Expires 1 Year From Date Issued Date Issued _--_______________.l <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 mad ijco ante with Coun y Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION .----- ----- --- ---- - ---------------__---_ CENSUS TRACT ---- _T._.-------- <br /> Owner's Name -- /c.e. c_- ------ --------------------------------------------- -------Phone --------------------.------ -------- <br /> Address ------J-3­5_7�-----S------------- = -•-------------- -----------• City ---S_�A.A/---------------------------------------------•------ <br /> Contractor's'Name ------------------- ------------------------------------------------------------------.License # --------- ------ Phone --------------------------- <br /> Installation will serve: Residence Apartment House❑ Commercial ❑Trailer Court ;❑ <br /> Motel ❑Other -------------------------------------------- <br /> Number of living units:... ------- Number of bedrooms __..-----Garbage Grinder A14_ 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 pubic sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ I SEPTIC TANK'[ Size_ _ ./_ ,X___6__/---------------- Liquid Depth -----�4__________- <br /> Capacity _1d�;,6U pe,&P ____ Material-C_c,'1.6,,eNo. Compartments _________ <br /> z-- <br /> Distance to nearest: Well ------ --------------.------------Foundation _.Ze------___ Prop. Line <br /> LEACHING LINE r} No. of Lines ----/_----------------- Length of each line_ ___Ll _r___-______ Total Length ----Gf -�._..___._._ <br /> o l� r <br /> 'D' Box -_� _ Type Filter Material _____________Depth Filter Material ----�__�?___-_.___-_.....______.____-_ <br /> Distance to nearest. Well --------------------- Foundation ------ 0__l____ Property Line ___S___/_ <br /> SEEPAGE PIT [ ] Depth ------------ Diameter ________________ Number ---------------------------- Rock Filled Yes ❑ No ❑ <br /> Water Table Depth ------------------------------------------------Rock Size ------------------------------- <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line --------..------------ <br /> REPAIR/ADDITION(Prey. Sanitation Permit# ____________________________________________ Date ----------------------------------11 <br /> SepticTank (Specify Requirements) - ------ -----------------------------------------------------------------------------------------------------1--------- ------------------- <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 su ct to Wor man's Compensation laws of California." <br /> Signed ---------------------------------------- Owner <br /> By -------------- ----------- --------- ------------------------------------------------------------------ -Title ------------------------- <br /> (if other than owner) <br /> FOR DEPARTMENT USE ONLY/ <br /> APPLICATION ACCEPTED BY - _ ______________ _ _ _ ___ ___ <br /> DATE _.___._ _,_"` ___________ <br /> BUILDING PERMIT ISSUED --- - ------------------------------ -DATE ----- ----------------------------------- <br /> ADDITIONALCOMMENTS ----------------------- -- ------ -------- ---- - ---- -- --------------------------------- <br /> F, <br /> ---------- -------------------- <br /> �- <br /> ff; '� �--- - = 1{' -� ------------ ------------ <br /> s <br /> ------------- <br /> ------ ------------ -- -----------------------------__ <br /> ` �------ <br /> Final Ins ection bDate __--- _-.- ----------- -- <br /> P y: --- <br /> SAN JOAO N LOCAL HEALTH DISTRICT <br /> . LI <br /> E. H. 9 1-'68 Rev. 5M <br />