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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> Y- { -�- <br /> ...i�-'._.,_.:.:'-, --- - Permit No. --•.. ..-...�:_�.� <br /> y (Complete in Triplicate) r <br /> Date Issued <br /> This Permit Expires 1 Year From Date Issued <br /> ---------- <br /> j! <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 <br /> �,/with <br /> J County Ordinance No. 549 and existing Rules and Regulations. <br /> f 7 /" `� Lr� --- ......-CENSUS TRACT <br /> JOB ADDRESS/LOCATION' .------------ _ <br /> Owner's Name--e- <br /> ------------------------- <br /> - Ph <br /> j: one <br /> �J - Eco ------•--- <br /> Address -... 7.9� ':. �7`lC - ---- � �.- U City �� ;. <br /> License # ...._.. 3 .yPhone <br /> Contractor's Name ...__ c.t .. `a - <br /> Residenc ] Apartment House-0 Commercial []Trailer Court <br /> Cl <br /> Installation will serve.• ❑ , <br /> lJhc-+.1__..L' 1---------•--- <br /> Mote! F1 Other __,_..___....-_...-. <br /> Number of living units r=--- Number of bedrooms :_-...Garbage Grinder -__—__.... Lot Size ...... ------------------ --------- -------- <br /> Water Supply: Public System and name - ---------------- ------- Private [� <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay Ff_-Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan D 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,) <br /> PACKAGE TREATMENT [ I SEPTIC TANK{ ] Size-----------------------------------------­------ Liquid <br /> - Depth - <br /> ----- ------------------- <br /> Capacity <br /> -------- ------ <br /> Ca acitY -��--------- --- Type -------------------- Material------- ------ -��- No. Compartments ---------------------- <br /> Distance <br /> ------------••--Distance to nearest: Well ------------------------------------foundation .-----.--------------- Prop. Line -------------------•-- <br /> LEACHING LINE [ ] No. of Lines ----------------------- Length of each line--.--------------------- --- Total Length --------.----..------------- <br /> 'D' Box - ----- Type Filter Material _------------------Depth Filter Material .-----..........--.-•.--.--•-----------•---- <br /> r Distance to nearest: Well ------------------------ Foundation . Property Line ..--_-------------_.__.. <br /> ------. Rock Filled Yes No <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number ---------.--------- - ❑ <br /> WaterTable Depth ------------------------------------------------Rock Size -------------------------------- <br /> Distance to nearest. Well ---------------------- Foundation - ------ Prop. Line ..--..._-._._..-_--- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ----------------- ------ Date ----------------------------------1 <br /> Septic Tank (Specify Requirements} --------------------- A' ---- ------- - ----- <br /> Disposal Field (Specify Requirements) -----------L--r�r- =........ 6- --X-- ----1--- --- - ` <br /> iS <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. (tome 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 shalt not employ any person in such manner <br /> as o a to becub'ect to Workman's Compensation laws of California." <br /> Sighed .. .. Owner <br /> �� Il "4: r <br /> • `"E-[.. - -- ------- Title . ..:..... . . ..'�-���"[{'------- <br /> (if <br /> - --(If other than own r) <br />'t FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY _-.-.. - -------------- DATE . ..... -------- <br /> BUILDINGPERMIT ISSUED ------------------------ ----------------------------------------------------- --------- ---- -DATE <br /> ADDITIONAL COMMENTS <br /> i ------- ---- ----------------------- ---------------- -------------- <br /> i Final Inspection by: .-- Date - <br /> r� ---- ---- - <br /> I <br /> I SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'6B Rev. 5M <br />