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FOR OFFICE USE: t <br /> p a " APPLICATION FOR SANITATION PERMIT <br /> 3 �� _ <br /> --------------- ------------------•------------------ - ,. ..�..... �. m Permit No. -f!✓ (,' <br /> �-!�plete in Triplicate) <br /> ! Date Issued <br /> - <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 compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> � n <br /> JOB ADDRESS/LOCATION _121 _77...... '...... ------------------------.-----CENSUS TRACT -------------- ----------- <br /> Owner's Name� � - �� «---------------- - -----------------Phone ------------------------------------ r <br /> I ^ � <br /> Address -------------------- -- .� -- ? = ------ City ------------------- <br /> _ k - ----- -- ------ - -------------------------•----------License # fes /"`--{'hone� J <br /> Contractor's Name __ ___. - �_ Q <br /> Installation will serve: Residence partment House❑ Commercial:❑Trailer Court )41 <br /> Motel ❑ Other ---- ------------------------ <br /> Number of living units:-_ ------ Number of bedrooms - ----_Garbage Grinder .! _ Lot Size ---- c E'er___________ <br /> Water Supply: Public System and name -- -- -------------- -------------------------------------------------------------------------------------.Private <br /> Pp Y� Y - - <br /> Character of soil to a depth of 3 feet. Sand ❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam.❑ <br /> Hardpan ❑ Adobe Fill Material ------------ If yes, type __________________________ <br /> (Plot plan, showing size of lot, location of system inrelation 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 f ] SEPTIC TANKe_____C? - _ ____ 1 -___ Liquid Depth ___,____ <br /> Capacity _________ Type _Lf_!_ Material _ <br /> ._- hrNo. Compartments <br /> 1 r <br /> �— •y = <br /> Distance to nearest: Well ------ ----------------------Foundation _�_______r_________ Prop. Line _ __________._.______ <br /> LEACHING LINE ;No. of lines __' _____________ Len 9th of each li)e�� _ 0 Total Len th � ua <br /> D' Box Type Filter Material{_,. Depth Filter Mat4rial ________________________________ <br /> Distant to nearest: Well- _60--1----------- Foundation -——--or _'._:___ Property Line -4 ---.---------_-- <br /> SEEPAGE P17 Depth Diameter _____ __________ Number ____-..._,:,_,,_f__________ Rock Filled Yes ❑ No ,0 <br /> Water-Table Depth ------------ -----------------------------------Rock Size -------------------------------- <br /> c~ Distance to nearest: Well -----------------------------------------Foundation -------------------- Prop. Line -___-----_----------_- , <br /> Rl:PA1R/ADDITION(Prev. Sanitation Permit# -'-,_.--------------------------------------- Date ---------------------------------- <br /> Septic'f '`'--- ,�- <br /> ank {Specify Requirements)'__.__- ==- --------------------------------------- ---------------- - - <br /> Disposal Field (Specify Requirements) ------------ <br /> -------- -t:, ±4-----•-----------------------------------------------------------------------------------------•--------------- I <br /> a � � l <br /> ------------ ---- ------------------------------------------------- -------------------------------------- --------- <br /> i <br /> i <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 Heol#h District. Home owner or licen- <br /> sed agents signature certifies the following: $ y <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 - <br /> --- ------ <br /> } # .. _. _ <br /> s <br /> =Owner _r <br /> um ---------------.-.�--. <br /> -- ------- <br /> $Y : r Title <br /> (If <br /> other tha w ] N <br /> " FOR .'DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED "BY'---- '>---- �3—�0� <br /> DATE �� <br /> BUILDINGPERMIT ISSUED ---- - ----------------------------------------------------------------- -------- -------------I-------DATE ------------------------------------------- <br /> ADDITIONAL,COMMENTS _____- - -- ----------------------- <br /> ------------------`--- ---=-=--- _- =-= e-5- c'-`5...V1of A...... 1s-------'k Act C$'t . -------� i �------------------------------------- <br /> ------- -- �-------------------------- --------------------------- -------------------------- ----------1- - -- -- <br /> -----------------------------'--- --- ------------------ - -- ------------------------------------------------------------------ ----------------- <br /> - -- -------- <br /> Final Inspection by: - - --------F5--------------------- ------------ Date <br /> SAN JOAQUIN LOCAL HEALTH,rDISTR4C--Tf-. <br /> E. H. 9 <br />