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rvx vrn�c voc- APPLICATION FOR SANITATION PERMIT <br /> _... ----------------- ` <br /> (Complete in Triplicate) r/ Permit No. 73-35-Z <br /> ..... .......................... .......... This Permit Expires 1Year From Date Issued / <br /> Date Issued.5 /.`F/..�3 <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 _....... r.2.-W.vw-1�i..-- ---------- _CENSUS TRACT ......----- ..........:... <br /> Owner's Name ..................... .................. ...... Phone .............................. <br /> Address ...................-..`�.e......................................................... ...... City ................. ...._................................................. <br /> ,.. <br /> Contractor's Name --------- _............... ---- ..............--- --..;_......License # .. ................ Phone ... _......_..._......... <br /> Installation will serve: Residence ❑Apartment House-[3 Commercial ❑Trailer Court It� <br /> Motel ❑Other........-............................. .. <br /> Number of living units:-------- --- Number of bedrooms ..------....Garbage Grinder ------------ Lot Size ...-------------- ----------------- - ------ <br /> Water Supply: Public System and name .---........ . ..............._....---....--.--......_.....----..------..-...--....---..---.....Private E� <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,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] Size........................ Liquid Depth .................... <br /> Capacity _.................. Type ...............---.. Material..._................ No. Compartments 6* <br /> Distance to nearest: Well ._-._..._................_.-....Foundation ...................... Prop. Line ...................... <br /> LEACHING LINE [ ] No. of Lines ..................... Length of each line.........------------ ...... Total Length ............................ C <br /> 'D' Box ..__..._- Type Filter Material ---------.-- ------ Filter Material .....--....__...--...--._................ G <br /> _ Distance to nearest: Well ......--- ----_.__. Foundation Property Line ........................ <br /> SEEPAGE PIT [ ] Depth __ -------------- Diameter ................ Number .............--------------- Rock Filled Yes ❑ No i❑ <br /> Water Table Depth ............... --------------------- ' "----Rock Size ------------------------- <br /> Distance to nearest: Well ........ ...............................Foundation .................... Prop. Line ..................... F <br /> A <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------..----------.--- -------------- Date --------------..------------------) 7 <br /> Septic Tank (Specify Requirements) ------------�-------�-------- �----_--_...... .................... 'f <br /> — Disposal Field (Specify Requirements) ...---LdG iC.-r�.er..ar:r...dr .......lC,7l?�..�. -t��-stc.K---«��-...1�-...-.-.- <br /> _ <br /> ----------- ----------------------------------------- -------- ...................... <br /> .. <br /> - - .._...._.. _... ........- . .... ................... . ...._............._...........................--............._.._-.. __. ......................... <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. Home owner or licen- <br /> sed agents signature certifies the following: <br /> "1 certify that in th performance of the work for which this permit is issued, I shall not employ any person in such manner <br /> as to be e s Ie t to Workm"rs Compensation laws of California." <br /> Signed , -- -- --" ..�JlJ--.._----------........._'-------------- Owner <br /> By _ _ _ _.._ ----- -- - - ...... ........- .....----------1. ........ Title ..._ _..__ - -. ... - - -.... .......... ............. <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ------------- Cr< -.—.............. . -........ ............. DATE ......------ <br /> BUILDINGPERMIT ISSUED ..... ............ -- .................. --- ............ ................... ...........DATE -----.............................. . -- <br /> ADDITIONALCOMMENTS .. .............. . ...........................................__......_........---..--------------------------------------- ..................-... <br /> ............. . . ............ ......... .'------'-- ..... -' --- . . .......................................................................................... . ........ <br /> -- ................. ---------------------- .. ....., .......- - 1 ................ ...-...... - .......-- .-.... ' <br /> ........................i--......... . .. - <br /> Inspection by: ... i�!JyG -­------------- <br /> SAN <br /> � !/L G C :' ..... ----­-------- <br /> Finalc-j .._/�-.. . ..... <br /> SAN JOAQ IN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M `", <br />