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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit No. _7L=- -5__C_. <br /> ----------I ------------------ ------- ------ <br /> I This Permit Expires 1 Year From Date Issued 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 /> le <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name -- ---------------------Phone ------------------------------------ <br /> - r - <br /> Address ----/�®-f--ky------ -- �-- - - ---------------------------. City _,04W------------------------- ------------------------------------- <br /> Contractor's Name _-. ---------------------------------------------- ------------------License # --- --------------------- Phone ------------------ <br /> Installation will serve: Residence ❑Apartment House❑ Commercial [ Trailer�C-atwt 48 <br /> Motel ❑Other -- ----------------------------------------- <br /> Number <br /> ---------------------------- ----------Number of living units-------i:'----- Number of bedrooms _ --------- Grinder --.--------- Lot Size .. ----" -l___ ---- <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 El <br /> Hardpan] Adobe.K] 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.) 4 <br /> NEW INSTALLATION: (No septic tank or seepage pit permittedif p blic sewer is available within 200 feet,) <br /> PACKAGE TREATMENT { ] SEPTIC TANK'k Size-- ' -_. ------------- Liquid Depth --�-_--___________--__ <br /> Material__ --Capacity Type _ -- ---_ __ No. Compartments ___ ............. <br /> Distance to nearest: Well ____, " -------------------------Foundation __ A_'_-'t__.__ Prop. Line _r_.........,______ <br /> LEACHING LINE No. of Lines --1----------------___ Length of each line._, ' -------------- Total Length ---107__-__________-- - <br /> 1 <br /> 'D' Bo ,} Type Filter Material .-------Depth f=ilter Material _-- ---------------- ----------------- <br /> Dista to nearest: Well -s :____'�________ Foundation ��--'_---_.______- Property Line �_-_-_'a'............. <br /> SEEPAGE PIT ) Depth _�°°_s57_____.___ Diameter _.r�__________ Number ------.�►---------------- Rock Filled Yes No i❑ <br /> Water Table Depth �'0_E-------------------------------------Rock Size . _._ __________ <br /> Distance to nearest: Well __AP�P_,___*----_------------Foundation <br /> s .__ Prop. Line -____ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ____________________________________________ Date ----------------------------------) <br /> Septic Tank (Specify Requirements) ----------------------------------------------------------------------------------------------------------- -------------------------------- <br /> Disposal Field (Specify Requirements) ------------------------------------------------------------------------------------------------------------------------------------- <br /> ---------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------- ------------------------ <br /> ----------------------------------------------------- - - - - - - ------------------------------------------------------------------------------------------------------------------------- <br /> (Draw existing and required addition on reverse side) <br /> 1 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 beco a subject o Wor an's Compensation laws of California." <br /> - ---- - - --- I------------------------------------------- Owner <br /> Signed _.� '_- __ __ ___ 0 <br /> BY ---------------------------------------------------------a-------------------------------------------- -Title <br /> --------------------------- - <br /> (If other thein owner) <br /> FOR DEPARTMENT USE ONLY �f <br /> APPLICATION ACCEPTED BY µ ------------------------------------------------------------ DATE -•------------------- <br /> BUILDINGPERMIT ISSUED ------------------------------------------------------------------------------------------ ---------------DATE -------------•----------------------------- <br /> ADDITIONALCOMMENTS -------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------- -- --- ------------- -- - <br /> ----•- <br /> ------------------------------------ ---- <br /> ---------------------------------------------------------- ----------------- - <br /> Final Inspection by =-!��± - -------Date <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />