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FOR,OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> -- --- --- ---- ------I�---------------- --------- ------ Permit o73-�- <br /> (Complete in Triplicate) _ ____________---------- <br /> ----- -------- -------- ---- --------- <br /> I� Date issued -�--------�__-• <br /> -------------------------- - ------------------------- This Permit Expires 1 Year From 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 /> JOB ADDRESS/LOCATION in <br /> dl �f 77,04 _CENSUS TRACT -------------- <br /> - Phone <br /> ___ g__'--��_____ <br /> Owner's) Name -- Phone <br /> --------- ----- --- <br /> Address.P pi----/-,3- "ti ------------------------------------------------------------ City � ��' / ------------------- - ---- ---- -- - ---- <br /> Contractor's Name _ _jam _ License # ------------- - ____ Phone __�� _ <br /> i <br /> Installation will serve: Residence ❑ Apartment House❑ Co mercial []Trailer Court ❑ <br /> Motel F1 Other _ _ [ _2:1__ __ <br /> Number .of living units------- Number of bedrooms --3-----Garbage Grinder ------------ Lot ________________ <br /> 11 <br /> Water Supply: Public System and name ---------------------- --------•-------------------------------------------•----------------------------------Private <br /> Character of soil to a depth of 3 feet: SandX Silt El Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam 'D <br /> Hardpan [❑ Adobe '❑ Fill Material ------------ If yes,type ________._________________ ] <br /> (Phot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> I <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK'[ J Size---- � _ -® Liquid Depth __ r- <br /> ----- -- <br /> Capacity/ -- __-,_- Type - --____-- aterial--- --- o. Compartments ---------- ----------- <br /> Distance to nearest: Well -------___ f i <br /> �_- -- -_-__--Foundation ___f�------------- Prop. Line ._�,�`--------____-- , <br /> - ----------- <br /> LEACHING LINE [ J No. of Lines ------Z-------------- Length of each line___/_._1.'�__Q_____.._____ Total Length ----------------------------- <br /> D' <br /> __ ___ _QD' Box ---- Type Filter Material P-O_ ------Depth Filter Material _ 1___________________________-_-_..- <br /> Distance to nearest: Well ------s-:�0__________ Foundation ___________ Property Line ________________________ <br /> SEEPAG PIT [ ] Depth ____________________ Diameter ________________ Number ---------------------------- Rock Filled Yes ❑ No I❑ <br /> Water Table Depth ------------------------------------------------Rock Size -------------------- <br /> Distance to nearest: Well ___________________________Foundation -------------------- Prop. Line _._.____..________..__ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ------------------------- ........ <br /> Septic'�Tank (Specify Requirements) ------------------------- ---------------------------- --------------------------------_ i <br /> Disposal Field {Specify Requirements] _______________________ _ _ _____ ----------------------------------------------- <br /> - - - ----------------------------------------------------- <br /> E _ --------------------------------------------------------------- <br /> -------- --- -- --- --- ------------------------ . <br /> [Draw existing and required addition on reverse side] <br /> I hereby certify that t 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 agenits signature certifies the following: <br /> "1 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 subject to Workman's Compensation laws of California." <br /> Signed I� ------- -- - ------------------------------------- Owner <br /> By ---------.M- it Title -- ------ ---- ----- - t <br /> - - - - - - - ------ --- <br /> (If other than owner] <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ------------ ---------------- ------------------------------------------------- DATE ---- `: �' ��---------- .• <br /> BUILDING PERMIT ISSUED ____.___.__ ___.___DATE ______________-________ <br /> - <br /> ADDITIONAL COMMENTS __.____.__ <br /> - •--- -00- 40", <br /> ------------- ---------------------- -------- --------------------- - ---- ----------------------------------------------------- -------------------- ------------------------------------ ------------- -- ---- -- ------- - - -Final Ins'`ectio -------------"--_-----------Date- - --- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />