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FOR OFFICE USE: <br /> Cl��J APPLICATION FOR SANITATION PERMIT <br /> Permit No. <br /> -------------------------------------------------- II--- <br /> (Complete in Triplicate) bate issued <br /> __.___ ___ ______ This Permit Expires 1 Year From Date Issued <br /> _ _ <br /> Application is hereby made to the San Joaquin Local Health District for a per to construct and install the work herein <br /> described. This application is made in co5pliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> tP <br /> C /T ON ADDRESS/LO , , ____.CENSUS TRACT <br /> Owner's Name ---G'-'------ -- ---- -�-�--:��--�-1------------------------------------------------------------------------------Phone ------------------------------•----- <br /> AX <br /> Address _� i� CityC! � <br /> F <br /> V� License # / hane�77 ' <br /> Contractor'shame _________ __ ______ <br /> Installation will serve: Residence M-115'artment House[] Commercial :❑Trailer Court J] <br /> Motel ❑Other ---------------------------------- --------- <br /> Number of living units:-----.1___ Number of bedrooms ----?—...Garbage...Garbage Grinder __'"____ Lot SlzeOje� � <br /> ------ ----- <br /> Water Supply: Public System and�name ---------------------- ------------------------------------------------•---------------------------------------Private <br /> r <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt 0 Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> -Hard <br /> pan ❑ Adobeaterial /f``1_ If yes, type ---------------------------- <br /> (Piot 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 permitteo.if'•public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT { ] SEPTIC TANKze--_�f j_ _____________________ Liquid Depth __ _____,_._.. <br /> , <br /> Capacity ---)_. -____-- Type 04-_e Materia /?CJ No. Compartments ..... <br /> -:__-- <br /> Distance to nearest. Well _n�L1___/_______I_________ <br /> LEACHING LINE _____Foundation/� ---------- -------- <br /> -__ Prop. Line ._ _� <br /> --=No. of Lines ------- G <br /> Length of each line---_----- --- Total Length <br /> .---------------------- <br /> rr� f <br /> `D' Box �i=----_ Type Filter Material _f_-� �F_Depth Filter Material _ ____�______________________________ <br /> Distance to nearest: Wel! ____ _-_______ Foundation __ _______________ Property Line +_____-_______.--..- <br /> SEEPAGE PIT (j/] Depth j <br /> �,,�-____-- _-- Diameterf_ "�i_______-- Number --------/-------�--__ -. Rock Filled Yes ®�[] <br /> Water Table Depth ----------- ---� -------------------------Rock Size /2_.Y----------------- <br /> J . <br /> Distance to nearest: Well ______-Qa_-------------------Foundation _._� ________ Prap. Line%S. <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ------------.__---__..__-_______) <br /> Septic Tank (Specify Requirements) --------_------------------------------------------------------------------------------------------------------ ----------------------- <br /> Disposal Field (Specify Requirements) --------- - ------ -------- -------------------------------------------- --------------- <br /> -- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------=------------------------ <br /> -------------- -------------------------------------- ----- -- -- ---------- --- <br /> [Draw existing and required -------------------------------------------------------------------------------------'------- <br /> - ------- <br /> 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, 1 shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed ---------------------------------------- - -------------- ` r Owner <br /> By ------------- ----------------------------------- "�� (J" 5 ------ Title ----- ----- <br /> ------------------------------- <br /> (if other than ow r <br /> FOR .DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED 8Y ------------ ------------------------------------------- DATE -----�-Z----6./-g <br /> ---------------- <br /> BUILDING PERMIT ISSUED --- j <br /> . ---- - DATE --------------- --------------------------- <br /> ADDITIONAL COMMENTS ----� ----------- ---------------------------------------------------------------------------- <br /> -------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------- <br /> ---------- <br /> ---------------------------------- ------- --------------------------------------------------------------------------------------------------------------------------------------- <br /> --------------------------------- <br /> ----- ------------------------------------------------------------Final Inspection by: Date ^-� <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'b$ Rev. 5M <br />