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FOR OFFICE USE:. APPLICATION FOR SANITATION PERMIT <br /> --------- - {Complete in Triplicate} <br /> Permit No,. -------------•------- <br /> -------- <br /> ---------- ----,---- ---- <br /> 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 compl'ance with County Ordinance No. 549 and existing Rules-and Regulations: <br /> JOB ADDRESS/LOC%TlN . ��/._. _.: k -- �-,.._ - ----CENSUS TRACT ---------------•----.._.. <br /> Owner's Name one <br /> _ Ph <br /> t <br /> Address <br /> ----------- J.Y. ---- - 'city - - <br /> Contractor's Name ------ ` l ----77a - ' .czl/jLice <br /> nse # - _3_ _ Phone . <br /> Installation will serve: Residence Apartment House,[] Commercial:E]Trailer Court C] <br /> Motel I]Other--------- - - --------------•--- <br /> -- - --- --- <br /> Number of living units:-----�.---- Number of bedrooms ...-__.__._-Garbage Grinder ........:.:. :Lot Size .. 'OT----"`" --"'---`-------- <br /> Water Supply: Public System and name --------------------------------------------------------------------------------------.. ------..Private <br /> Character of soil to a depth of 3 feet: Sand'E] Silt Clay (] Peat.ft Sandy Loam Clay Loam:Q <br /> -Hardpan 0 Adobe:E] Fill Material 1,°N'' -_:Wyes;'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,top i <br /> ) r <br /> PACKAGE TREATMENT [ ] SEPTIC TANK. Size_�l.-_XJ....�.:.................. Liquid Depth _.r±' -------------- Q <br /> Capacity ._Ifl _ Type �ot Material__ - + -_F.. No. Compartments ._ _-_.--•._. <br /> Distance to near t: Well ._-__.� .._..____-------------Foundation __.J..0............. Prop. Line .-A---------:_---__ <br /> LEACHING LINE [ No. of 'Lines .____-1............... Length of each line-_-.--_.C:D-IJ-----...---• Total Length ,__100------.----..-.-- <br /> . <br /> 'D' Box .." _ Type Filter Material':_."-�_1. � -Depth Filter Material ------ _-----_---•---•-•---- <br /> Distance to nearest: Well ------ p--- -----� . Foundation .-- / :--:._. Property Line ---~t.........-------- <br /> -1 <br /> S J Rock --!----------------/- Rock Filled Yes No IQ <br /> [7i] <br /> Depth - D+ �p Number to <br /> Water Table Depth ----------- k- ---- ----_------ ------ - Size X LI.Y----------- <br /> Distance to nearest: Well ....--__._ lbP____________________Foundation __..�f�.-__..-.--_ Prop. Line _.-'S...._._...--.-_- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# •------•---•--------------------------- - - Date ................••--•-----•-•-•---) <br /> Septic Tank {Specify Requirements) ------ ----- ---------------- ---------------------------------------------- <br /> Disposal Field (Specify Requirements) <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 ownef 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's Compensation laws of California." <br /> Signed --- ------------------- OwnerT / <br /> i BY '`� _ Title - 4�r�=_ �. --•------- ... <br /> / <br /> If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY - -- --•---------------•-------------•------- DATE .cS`..=% .�:` ` ----------- <br /> iBUILDING PERMIT ISSUED ------------------------------ --------------_-_- -----------_--- ----------------- ---------DATE ----------•----------...----- - <br /> ADDITIONALCOMMENTS - -=---------- -•--------•-----•--------------------•-------------- .... .• --------------------------------- ............ . <br /> ----------- - ------------- -------------------------------------•------•---------------- ---------- -----------••-----------------------------•------------ -------------_ <br /> --------------- ---------­-- -•-- ----------------------------- -------------- ------------------------_. -•--------I------------- ----------------- --------- ------------ ----- <br /> ------------------­ •---- - -------'------- <br /> Final Inspection b - ._--Date <br /> -- ------------ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E_ H. 9 1-'68 Rev. 5M �`' <br />