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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> Permit No: <br /> -----------------------------------------------------------_ <br /> .,v "tComplete in Triplicate) <br /> Date Issued -------------------- <br /> - This Permit Expires 3 Year From Date Issued <br /> --- ----------------------•--------------------- ---- <br /> Application is hereby made to the San Joaquin focal Health District fora per to construct and install the work herein <br /> described. This application is made in compliance with County Ordinance No. 5 �and�xin,�R}}}esnd�'la_tj-,ons: <br /> JOB ADDRESS/LOCATION 'v'J_=--- -- -- _ - ----------------------- --CENSUS TRACT -------- <br /> I ---------------Phone ---------------------- ------------- <br /> Owner's <br /> - ---- <br /> Owner's Name ---- - ------- Phone <br /> ---- - ------------ <br /> - ----- -- <br /> Address ----------------- ---- -------- ----------------------------------------------------------- City --------------------------------- ------- ---•------------------------------- <br /> Contractor's Name1 <br /> --------------License #._61-, Phone ----------------------------- <br /> Installation <br /> ------------------ ----------Installation will serve: Residence K <br /> Apartment House❑ Commercial ❑Trailer Court ;❑ <br /> Motel ❑Other -------------------------------------------- <br /> le <br /> Number of living units------f----- Number of bedrooms __02._...Garbage Grinder Lot Size -ax-A-41-1t- ---------------•--- <br /> Water Supply: Public System and name -----------------------------------•------------------------------------------ -------------------------------Private i <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam91 <br /> Clay Loam ❑ <br /> Hardpan ❑ Adobe.0 Fill Material ----- ----_- If yes,type ------------------------ <br /> tit <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 sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK Si.e-_-1YJ_X__9------------------------- Liquid Depth _/-/--------------------- <br /> Capacity <br /> _-__-_--_----,----- <br /> _P-C:9f4"Material-----.- No. Compartments Capacity_-ts��-Q---•-- Type --o9f4-Material �---------` � p -••---....:.--- <br /> Distance to nearest: Well ------____ _----------------Foundation-----�d--------- Prop. Line <br /> LEACHING LINE [ j No. of Lines -----,�------------- Length of each line-------_�0_ ------------ Total Length ---�+t __-............. <br /> 'D' Box -�- _ Type Filter Material .ee. -Depth Filter/Material --___ ----------------------- <br /> Distance -to <br /> ------Distance;-to nearest: Well -------- Foundation ------------ Property Line- .......... <br /> SEEPAGE PIT [ ] Depth -- ---------------- Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No i❑ <br /> r <br /> Water"TaI ----------------------- - <br /> ble Depth -----------------------Rock Size -------------------------- <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line --.------------------- <br /> F I <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date .-_-_--_.____--_-_------------_.--} <br /> r <br /> SepticTank (Specify Requirements) ----------- -------- ---------------------------------------------------------------;- -----------.--„---------------------------- <br /> Disposal Field {Specify Requirements) ---- --------------------------------------- ---------------------------------------------- <br /> ---- ---------ca�------Z ------- ------' t '-� J`-� <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 /> 1 secs agents signature certifies the following: <br /> "I certify that in the performance of the work Aor which this permit is issued, I shall not employ any person in such manner <br /> as to becomes ct to km 's Compe atron [aws of California." <br /> Si ne Z ------------------ Owner <br /> BY ----------------------------------- '-------------------------------------------------------° --------- Title ------------------------------------------------------- ---------------- <br /> - <br /> (If other than owner) <br /> R .DEPARTMENT USE ONLY <br /> I <br /> DATE --- -------- --~Z0-------APPLICATION ACCEPTED BY -- ---- ------ ------ - ---------- --- --------- <br /> BUILDINGPERMIT ISSUED ---------r------------------------------------------- ----------- ---------------------------------------DATE ------------------------------------------- <br /> ADDITIONALCOMMENTS ---------------------------------- ------------- ---------------------------------------------------------------- -------------- <br /> ----------------------------------------------------------------------------------------•-------------------------- <br /> t <br /> - -------------------------------------------------------------- <br /> ------------------- --- <br /> - -- -------- - - <br /> z <br /> -Final Inspection b ------------------ -------------------------------------------.Date --- "- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />