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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> Permit No: <br /> -- ----------------------------------------------------- <br /> � (Complete in Triplicate) t <br /> Date Issued --r --- ���'� <br /> This Permit Expires 1 Year From Date Issued <br /> ----------------------------•----- ----- <br /> v` —r- - 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 made in compliance with County Ordinance No. 549 and existing Rules and Regulations: , <br /> ' -_�JU ' CENSUS TRACT ------------- <br /> JOB ADDRESS/LOCATION -------- --- JJ <br /> I Owner's Name-a-:7 / [-------------- <br /> -------Phone----------------------------- ------- <br /> C_,1- �1!-G --- <br /> Address ----------- i _W.�........ ----------�--- ------- City ���LG �-3•.._ . <br /> i <br /> Contractor's Name --�__-.-� <br /> 7 � � ,G)__SL c�e# .-(�---------------- PhoneJ- <br /> ,_ <br /> i <br /> Installation will serve: Residence NApartment House,❑ Commercial ❑Trailer Court ❑ <br /> Motel ❑Other -------- ---------------- f <br /> Number of living units---_-- Number of bedrooms --__ --___ Garbage Grinder ./V-a---- Lot Size l--�--��- `�`s- <br /> 9 �---- - <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 sewer is available within 200 feet,) O <br /> PACKAGE TRI=ATMENT,� ] SEPTIC TANK'[ ] Size-------------------------------------------"r_ `Liquid Depth -------------------------- <br /> Is7/ Ca acit i T e -------------------- Material---------------------- No.: Compartments ------ ------- ------- "A <br /> PY ------------------- YP 44 <br /> ��i/ Distance to 4`hearest- Well ------------------------------------Foundation ----------- ,a----- Prop. Line ----.--------_------- <br /> LEACHING LINE't [ ] P. of Lines-------------------------- Length of each line------------------ ------ Total Length :--------------------------- <br /> , -De Depth Filter./'Material --_'b' Box .--�_��_.- Type Filter Material ---- ------------ P i� - -------------------------••-----•------, <br /> r„ Distance to nearest: Well ------------------------ Foundation �_�'- ----__ Property Line. --_-_------_. <br /> SEEPAGE PIT [ ] ;9epth s'___--_--- Diameter -__-_-__-_-_--- Number ----------------- Rock Filled Yes ❑ No .ID <br /> Water Table�Depth -` _ Rock Size -------------------------------- <br /> -- <br /> x13 4 =1 oundation Pro Line ---------------------- <br /> Distance to nearest: Well ---------------------------- -------------------- p <br /> (Prev. Sanitation Permit# ------- ----- - ----- Date ---------------------------------- <br /> REPAIR/ADDITION '-1 <br /> i \ <br /> Septic Tank (Specify Requirements) --------- ----- ------------ ------- --------------- --- ---- �- --------, -. ,< -------- ------- <br /> ------------------------ <br /> 0-X <br /> -- <br /> ----- ---- - --- <br /> Disposai Field Specify Re'qui�ements) --_-____-� - --Y- � - - --- ----- ---- - -� ,t f <br /> ------------------------------------------------------------ <br /> ------------------------------------------------- -------------------------------- --- ----- -------------- <br /> -� - ----------- ---- <br /> _ ------------------------------------------- > <br /> L..r ---- '_------------------------------------------•----- ;. <br /> f (Draw existing and required addition on reverse side) f ; <br /> I hereby certify,that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordina cn es, 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 ject to Workman' mpensati.on laws of Ccilifbrnib." <br /> 1_ l € <br /> i <br /> Signed ���-.,r�� -- - - ------------------- -------- --------• Owner <br /> 41 <br /> ------------J----'--------------`- <br /> - -�--- Title x f ------------------------------- <br /> (If other than owner) __ 1 <br /> FOR,DEPART NT USE ONLY �- <br /> __ . <br /> APPLICATION ACCEPTED BY r DATE <br /> ----- - -- -- ---------------- - -- --------- - -- ----- <br /> BUILDING PERMIT ISSUED ------------------------- ----- - - DATE -.- <br /> - - - - ----------------------------------------- <br /> ADDITIONAL COMMENTS ------------------ ' ---- .--- - <br /> - - <br /> -- ------------------------------- ---- <br /> -- ------ - --------- ----------------------------------------------------------------- to - <br /> Final inspection by. <br /> ------- Date �( <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M. <br />