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FOR OFFIC) USE: <br /> I i APPLICATION FOR SANITATION PERMIT <br /> ---------------------------------------I--------------- Permit No:7Z -1 <br /> (Complete in Triplicate) # <br /> -------- f This Permit Expires 1 Year From Date Issued 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 compliance0 Co'my Ordinq%e No 54 and existing Rules and Regulations: <br /> /7 7 <br /> JOB ADDRESS/LOCATION .__-__ UZAr lJ_ ------e;4rkk�----.L.l�� ---=/----------------CENSUS TRACT _.-------------........... <br /> Owner's Name ------ ------------- --I---- 5 �� fi'� ------------ ------.Phone ----------•--------- <br /> Address - ` ------=---------------------------------------------•--• City -=---- =W7e <br /> Contractor's Name !r[ly_{1e_n----- e - ---- -------------- --------License # -------------------------- Phone --------------------.....-..._ <br /> Installation will serve: Residence 2-6-artment House ❑ Commercial ❑Trailer Court ;1] <br /> Motel ❑ Other -------------------------------------------- <br /> Number of living units:______ ___ Number of bedrooms ---3- Grinder ------------ Lot Size ____________________________________...___ r <br /> Water Supply: Public System and name --------------------------------•----------------------------- ------------------------------------------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand'21'�`Silt❑ Clay ❑ Peat❑ Sandy Loam [] Clay Loam ❑ <br /> Hardpan ❑ Adobe'❑ Fill Material ___________ If yes, type ____________________________ <br /> (Plot pian, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) `t <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) pr, <br /> PACKAGE TREATMENT [ SEPTIC TANK:[ I Size____ _Z_.___ Liquid Depth ----4D_______________• �. <br /> Capacity .4�.U-_G_-•-- Type -------------------- Material-------- --- No. Compartments ---cam •-•---. i <br /> Distance to nearest: Well -____--C:54 _________________Foundation __ (�?____________ Prop. Line -------j5_...-.-_____ <br /> LEACHING LINE [ j No. of Lines ----IQ Length of each line_.____ 0--------.------ Total Length ---------------------------- <br /> 'D' Box _ _______ Type Filter Material x'_0'1 _Depth Filter Material -__ ________________________________ <br /> Distance to nearest: Well ------------------------ Foundation--------------------------'Property Line. _------_---_-_____-_.___ <br /> SEEPAGE PIT [ ] Depth ------j_______-- Diameter ________________ Number ---------------------------- Rock Filled Yes ❑ No <br /> Water Table Depth ---:--------------------------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well ----------------------------------------Foundation --------------------- Prop. Line ---------------------- <br /> REPAIR/ADDITION(Prev. <br /> ---------------------REPAIR/ADDITION(Prev. Sanitation.Permit# -------------------------------------------- Date ----------------------------------J ) <br /> Septic Tank'(Specify Requirements) ---- --- -- ----------------------------------------r----------------------.-,-------------------=- ------ <br /> DisposalField (Specify Requirements) ------------------------------------------------------------------------------------------------------------------------------------- <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 "e work for which this permit is issued, I shall not employ any person in such manner # <br /> as to b subject to Workm omp sati. aws of California." # <br /> / 4 <br /> Signed �C t ----•------------------- Own i <br /> �a <br /> Title' 4- -------- -- - -- ----- ------------- <br /> ( f other than owner) <br /> a F R DEPASTMENT USE ONLY <br /> ----- DATE 3..a `a ' �- •---- <br /> APPLICATION ACCEPTED BY ___-_.__: -_ _ ____ <br /> BUILDINGPERMIT ISSUED -------------A--------------------------------------------------------------------------------------------DATE -------------------------------- ---------- <br /> ADDITIONAL COMMENTS --------------'--------------------------------------------------------------------------------------------------------- <br /> ----- -- ------ <br /> ---------------------------------------------------------'------------------------------------------------------------------------------------------------------------------------------------------------ <br /> ------------ ------------------------------------------------------------------------------------- <br /> ------------------------------------------ --------- ------ <br /> - --- -- <br /> , =- <br /> -- ZFinal Inspection b -- -------- <br /> ---_Date -- --- - ______________ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />