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' FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> .................................................. Permit No� - <br /> (Complete in Triplicate) <br /> $ <br /> .............................................. <br /> ...... ...............••-.._.._ <br /> r Date Issued z(�.�_.•-`•,/� <br /> -------------.............................•------- . This Permit Expires 1 Year From Date Issued i <br /> t <br /> Application"is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein <br /> described.IThis application is made in compliance with County Ordi gnce No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION. ... ...........................CENSUS TRACT .......................... <br /> Owner's Name ...__ Tit.�------- .o. .. .l� .n................................................................Phone .9t!--... 1. . <br /> Address ................... .•dn'..(?.. ;............-------- ..............................City .............-........... <br /> . i <br /> i� <br /> Contractor's Name -------.�:�-�...._..--i.............................................................License # ........................ Phone ...._...----._.... ........... <br /> Installation will serve: Residence[]Apartment House Commercial❑Trailer Court ❑ <br /> Motel ❑Other............... <br /> Number of living units.... Number of bedrooms Garbage Grinder Lot Size l ° '" �e'� 1 <br /> Water Supply: Public System and name .....• ......................................_..............------------................................Private ❑ <br /> Character of soil to a depth of 3 feet: Sand [jz=Silt❑ ;Clay 0 ; Peaf <br /> El 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: lNo septic tank or seepage pit permittedif pubiic sewer is avpilable within 200 feet,J <br /> Li lS� <br /> PACKAGE TREATMENT [ ] SEPTIC TANK; J Size............................................. .. Liquid Depth p ...............•-•----.... <br /> ` Material.............:....'._ No. Compartments <br /> Distance to nearest: Well ------ -----------•---•__---.......Foundation ....................^. Prop: Line ...................... <br /> LEACHING LINE [ j No. of'Lines ----------------------- Length of eachline-'.._......._.....•_-..-.... Total Length ........._......---. ...... rn <br /> 'D' Box ----------.. Type Filter Material ....................Depth Filter Material ..................................... <br /> Distance to nearest: Well ------------------------ Foundation ........................ -Property Line ........................ <br /> SEEPAGE PIT [ ) Depth ------ ------------- Diameter ................ Number ------ --------------------- Rock Filled Yes ❑ No <br /> Water Table Depth _-_------------ ...............................Rock Size ................................ �- <br /> p. <br /> = Distance to`nearest: Well ----------------------------------------Foundation. .................... Prop. Line ............__....-� <br /> REPAIR/ADDITION(Prey. Sanitation Permit# ........................_-.-----------.---- Date ___- :-_:-----_J' <br /> t 9 <br /> Septic Tank (Specify Requirements[ ................ ........... .. <br /> ......................._... . . . <br /> Dispos 1 Field (Specify Requirements) ------1.7 °I.�.�'- 1t --------- �-- ._---- .._:1..'P �./7 ...5 ..... <br /> ------------- •-•---•--`'- !�C.. . > -�j ..-.---�'�j� '--- ----------- -- <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. Horne owner or licen- <br /> sed agents signature certifies the following: ft .. .�,� .�.'_ - - -f <br /> "I certify that in the performance of the work for whiih 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'- ----------------------------- ------------------ . Owner <br /> J - Title • F ... <br /> BY --•-------------------------------------------- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY j <br /> APPLICATION ACCEPTED BY --- -- - ---- ----------- ------ ------------------------------------------------ DATE .... --------- <br /> BUILDING <br /> ---- ---BUILDING PERMIT ISSUED -------------------- -- -- r <br /> ---•...------.......................... ............------•--�..--•--- -------©ATE .......... <br /> -.......... .,................ <br /> ADDITION L COMMENTS ..... . ........ <br /> a , <br /> --- <br /> ............-----------------------------------------.. -------------------------------------- ------------ ---- . .C..L-. <br /> Final Inspection b ....Date .. .. .... <br /> ......•--.-•---,.---------_----- <br /> EH 13 24 1-68 Ifev. ,M SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M �' <br />