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i <br /> FOR OFFICE USE: 'BAPPLICATION FOR SANITATION PERMIT <br /> k <br /> ------------------ <br /> ' Permit No. <br /> - <br /> (Complete in Triplicate) <br /> ------------ --------------------------- <br /> Date Issued <br /> -------------------- ----- -------- _---------- This Permit Expires 1 Year From bate 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 compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> a <br /> JOB ADDRESS/LOCATION- ------9_1d-t------- ere-14-101G/lVf'-------------- ----------- -- -----------CENSUS TRACT -------------- ------- <br /> _ J �� <br /> Owner's Name -------(�' - ��---��--4J(�---------------------------- - ------.------------------- <br /> -------------- ---Phone --------- <br /> Address --------------- ----�X_/NG---------------- . City -----TeAG�/--------------------------------------------------- <br /> ' Contractor's Name.---.: .�L G_;�----- __----- :.— =-_=`�'` -g_License #v`l,? -- 4 --- Phone <br /> Installation will serve: Residence P Apartment House°❑ Commercial :❑Trailer Court ;❑ <br /> Motel ❑Other --------------------------------------------- <br /> Number of living units:._-- ______ Number of bedrooms ______Garbage Grinder --------- -- Lot Size __. -r4G ------------------ <br /> r '� <br /> i Water Supply: Public System and name --------------------------------------------------I---------------------------------------•--------- ------Private <br /> Character of soil to a depth of 3 feet: Sand'❑ ,Silt C1 Clay T__"Peat El 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 /> _ Liquid <br /> Depth ----- ------- <br /> PACKAGE TREATMENT SEPTIC TANK [ ] Size_____ X!Q <br /> _____ % X6__._._ <br /> E__Material______________________ No. Compartments Capacity ��_�`- -�------- Type �!Q �' p ------ ----•-•-------- C <br /> -- -------- <br /> _ 4. <br /> IDistance to nearest: Well ___-b_-0------------------------ __ ---__------ Prop. Line ___`A__6 ...,___.__ <br /> LEACHING LINE [ ] No. of Lines ---- Length of each line_____¢--- Total Length -r ¢-_-..---------- <br /> 'D' Box {___/------ Type Filter Material �/a�,�'�___Depth Filter Material I___---!_____________ _______- _. - <br /> Distance to-nearest: Well ___ G____ _________ Foundation _-L6---------------- Property Line -' ___.-------- ...... <br /> SEEPAGE PIT [ I Depth _ ----- <br /> -_____ -_ Diameter ________________ Number - ------------------------- Rock Filled Yes ❑ No ❑ <br /> WaterTable Depth ------------------------------------------------Rock Size -------------------------------- <br /> Distance <br /> ----------- --- - - •-•----- <br /> Distance to nearest: Well ----------------------------------------Foundation --------------------- Prop. Line ----------- .......... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ---_----------------_.------------) <br /> SepticTank (Specify Requirements) -----------------------=------------------------------- --------------------------;-----------------..--------------------------- <br /> DisposalField (Specify Requirements) -------------- ------------------ ------------------------------------------------------ ----------------------- --------------- <br /> ------------------- -------------------------------------- ------------------------------------------ ----------------- <br /> ------ --------------------------------------------------------------- ---- ----------------------------------------------------------------------------------------------------------------- <br /> (Draw existing and required addition on reverse side) <br /> certifyprepared <br /> I hereby that 1 have 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 sub)e t to orkman's Compensation laws of California." <br /> ---- Owner <br /> Owner <br /> Signed - . <br /> er,4y- <br /> BY --------------------------- - ----------_-------------------- ----------------------------------- Title -------------------- - -------------------------------------------------- <br /> (if <br /> --- -------------------- ----------------------- <br /> (if other than owner) <br /> yy} FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BYt -------- ----------------------- <br /> ---------------------------------------- DATE ----- S-------- ------------------ <br /> BUILDINGPERMIT ISSUED ----------------------------------------------------------------------------------------------------------DATE ------------------------------------------.. <br /> ADDITIONALCOMMENTS -------------------------------------------------------------------•---------- ------------------------------------- --------------- -------- ----------------- <br /> ------------------------------- <br /> ----------------------------------------------------------------------------------------------------- <br /> ---------------------------------------------------------------------- <br /> ----------------------------"------------ ---------------•- <br /> ---- ---- - - -------- <br /> - - <br /> Final Inspection by- -------------------- ---- ----- - - ------------ -Date ----- -- <br /> -----------------------. <br /> SAN JOAQUIN LOCAL HEALT ISTRICT <br /> i <br /> E. H. 9 1-'b8 Rev. 5M <br />