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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit No. �_/-/_(_� __.__. <br /> - ---- --------------- / <br /> _---------------_-_-__------.------__------------- This Permit Expires 1 Year From Date Issued <br /> Date Issued _(_Z _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/LOCAT I 6? .) yl-'-- �"c s`1 ----- -------- ------CENSUS TRACT ---------- --------------- <br /> Owner's Name -------><J )- -- ------ ------ -- ---------------- --------- ------------------ --- Phone ------ ------ --------------------- <br /> Address �-1 -------- ''`t�--- ---------------- ------------ City e <br /> ------_---------------------------------- <br /> Contractor's Name - --- ----- ------- ------ �'z.f ------ :/vr s _License # _f� - eX 3 Phone ------------------------------ <br /> Installation will serve: Resident Apartment House❑ Commercial ❑Trailer Court ;❑ <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 [n"� 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 [ ] SEPTI fTANK'[ lSize_5-__�f---1-0__..:�(._.�� .--�r}�-___ Liquid Depth ..�._.�_______- \ <br /> �p ks.c.�$'--- Material No. Compartments Capacity - 0-C� TYPee�' P <br /> Distance to nearest: Well ----------15,1P._I'--------------Foundation .__1.0_.__.._._. Prop. Line _L5-' -- <br /> - r <br /> s <br /> LEACHING LINE [ No. of Lines _____._ __.______._ Length of each line-_- � b7-A__-__------ Total Length -PD_______ <br /> 'D' Box --- ----- <br /> Type Filter Material .__rS--- --------Depth Filter Material -----A__l-__ `___________________________ <br /> C, <br /> Distance to nearest: Well ____50./.___-_- Foundation ___ �.�__..-___. Property Line ._.v_________________ <br /> SEEPAGE PIT [ J Depth -----------------I--- Diameter ---------------- Number ________________________ Rock Filled Yes ❑ No 0 <br /> Water Table Depth ------------------- -------------- -------Rock Size -------------------------------- <br /> Distance to nearest: Well ----------------------------------------Foundation ____--._.-.____.____ Prop. Line ---____-_-_.____-___-- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -----------------------------------------.-- Date ----------------------------------) <br /> I <br /> Septic Tank (Specify Requirements) ______--__---____ <br /> ---------------------------------------------------------------------------------------- <br /> DisposalField (Specify Requirements) ---------- ------------- ------------------------------- ------ --------------------------------------------- -----_--------------- <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 /> "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 become subject to Workman' Compensation laws of California." <br /> Signed - . Owner <br /> _ <br /> B 'Ll _ � <br /> l "r,_ --- .. � — Title ? <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY --- - - —AMAI ----------------------------- ---------------- <br /> ��- 3 <br /> -------------- ------ - -------- -. DATE . <br /> BUILDINGPERMIT ISSUED ---------------------------------------------------------------------------------------------- -----------DATE --- -- `-------------------- -------------- <br /> ADDITIONAL COMMENTS ------ ------ ----------------------- --------------------------------------- ------------ ;-----._- _ <br /> ----------------------------------------------------- <br /> --------------------------------------------------- <br /> ------ <br /> --------------------------------------------------------------------------------------------------------------- <br /> --- -------------- <br /> ---------­------------------- - -- =------- <br /> Final Ins ection b J� -1 - <br /> C��- --- ---- - ---------- Date - <br /> ----- -- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br />