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FOR OFFICE USE: II . <br /> i APPLICATION FOR SANITATION PERMIT <br /> - --------------------- -----•-------------- �� - Permit No: __��- ----- <br /> ---------- <br /> So� <br /> 'j (Complete in Triplicate} <br /> -------------------------------------- --------------- - <br /> _________'__ This Permit Expires i Year From Date Issued Date Issued _rl.�_r a b <br /> Application is hereby made 11to the San Joaquin Local Health District for a permit to construct and install the work herein ! <br /> described. This application iP s made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> 67 JOB ADDRI=SS/LOCATION ._+.1 J__SS- —7-------- + i. ---------------CENSUS TRACT --------------.----------- <br /> 19-1 <br /> Owner's Name - --- - -- ---------------Phone------------------------- ---- <br /> I. <br /> AddressA�-W __. city ----------------------------- ---------------------- <br /> Contractor's Name ------------ <br /> ---- -- --- -------------License # Phone ------------------ ---•-•---- <br /> Installation will serve: II Residence Apartment House❑ Commercial:❑Trailer Court ❑ <br /> Number of livingunits:______ _ Number of bedrooms _____ ______Garbo a Gr <br /> Motel ❑Other-------------------------g -_ <br /> - , - finder ------------ Lot Size -•----------------�------�------------ ----- <br /> Water Supp I Y- PubIicSystem fand name -------------------------------------------------------------------------------------- --------- Private <br /> Character of soil to a depth o,f3 feet: Sand❑ Silt 0 Clay .❑ Peat❑ Sandy Loam lay Loam❑ <br /> ii 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 /> PACKAGE TREATMENT [ ] SEPTIC TANK I ] Size------------------------------------------------ Liquid Depth ---------------------..._--� <br /> Capacity ----------------- Type -------------------- Material---------------------- No. Compartments -------------- a <br /> Distance to nearest: Well ____________________________________Foundation ______________________ Prop. Line ______________________ <br /> LEACHING LINT= [ ] No. lof Lines ------------------------ Length of each line---------------------------- Total Length -----------___________------ <br /> 'D' Box ------------ Type Filter Material ---------------------Depth Filter Material --------------------- <br /> Distance to nearest: Well ---_-------------------- <br /> r <br /> .Foundation ------------------------ Property Line. ---------•---------=---= <br /> SEEPAGE PITDe th ____________________ Diameter.,(_---- __ Number --------------------------------------------------------- El__ _______________________ Rock Filled Yes No 0 <br /> � ) P <br /> Water Table Depth ------------------------- "=------------Rock Size ------------------ -------- <br /> Distance to nearest: Vllell ------------------------------------.:_Foundation -------------------- Prop. Line ------------ <br /> REPAIR/ADDITION(Prev. Sanitation Permit*# _________-----------------------------------aw Date ____________ _ <br /> --------------------1 <br /> Septic Tank JSpecify Requirements) --------------------------- - --- -----------z,.-------------------------- <br /> Disposal field { Peeq --- -------- --- --------------------= --cify ,R3 <br /> 1 - <br /> i <br /> ------------------------------------- -------------------------------=----------------------------------------------------------------------------------------------------------------- <br /> �I (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 Focal Health District. Home awner or licen- <br /> sed agents signature certifies the following: <br /> 11 certify that in the performance of the work for which this permit is.issued, 1 shall not employ any person in such manner ' <br /> as to become subject to Wo an's Compensation 19W of California." <br /> Signed ------------------------------ - ----------- -- -- - - ------- - -------------- Owner <br /> BY ----------------------------------- - ;-- - - - ----� - xitle, �`¢" � ' <br /> (If other than owner) - <br /> I� FOR .DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ----------------- --------------------------------------- ------------- DATE - ------------------ <br /> BUILDING PERMIT ISSUED -------- -- ---------------- ------------------- = `- ------------DATE ------------------------------------------- <br /> ADDITIONAL COMMENTS `----------------------- ------------- <br /> ----------------------------------------------- = <br /> ------------------------------- ---------- --- -------------------- ------------------------------------------------------------------------------------------------------------------------ <br /> -------------- <br /> --------------- --------------- ----------- -- -- --- --=------------ -- <br /> --------------------------------------------------------------------------------- <br /> Final Inspection b ---- ------ DateY <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ii <br /> E. H. 9 1-'GB Rev. SM. if s <br /> I - , <br />