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FOR OFFICE USE: II <br /> APPLICATION FOR'_SANITATION PERMIT <br /> --------------------- <br /> Permit No_ __ _ _______ ____ <br /> II (Complete in Triplicate) r _ - -7/ <br /> ---- ---_- This Permit Expires 1 Year From Date Issued Date Issued <br /> Application is hereby made to the San oaquin 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 /> I ca o <br /> ' JOB ADDRESS/LO TION' .----'�'f � ��. .= - - - CENSUS TRACT --------------------------- <br /> -------------Owner's Name ---- ----------------------------------------------------- - --- <br /> --�---- -----� ----Phone. � 6 <br /> AddressJ --- ------ = - --------------•--. City ----- --- --------j---------------------------------- <br /> f +. <br /> Contr <br /> actor's Name - L --•---------_.. ... - ------:License # _26.+ Q J!--- Phone 1163 oHI�!... <br /> Installation will serve: Residence [K Apartment House�❑ Commercial :❑Trailer Court ❑ 1 <br /> Motel ❑ Other --------- -------------- ---------------- <br /> Number of living units:_ l,____ Number of bedrooms ----_.Garbage Grinder -__ _' Lot Size ---- -_� _t ________. <br /> f : <br /> - <br /> Water Supply: Public System and name ---------------- ----- ------Private El <br /> Character of soil to a depth of 3 feet: Sand'[] Silt E] Clay ❑ Peat El Sandy Loam -E] Clay' Loam.r[-] <br /> r ._ � <br /> Hai_rdpari❑ Adobe Fill Material 7'If yes;type _ _ _-_ <br /> (Plot plan, showing size of lot, locaii'ion 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,I <br /> PACKAGE TREATMENT { ,] ( ] Siv <br /> SEPTIC TANK:( ze-------------------•----------------�-------- - Liquid Depth -------------------------- Q► <br /> Capacity ------I Type ---------- - ,_ Material-------- ----------' No. Compartments -------------- ....... '� <br /> Distance to nearest: Well ----__:'_'_:______--Foundation --- Prop. Line ______________________ <br /> LEACHING LINE N Li '-------/-.-________ Length of each line____/!�Z7____-------- Total Length __�Q__/________._ <br /> ' 'D Box Lines�____ Type Filter Material _______s�_.__i!__Depth Filter. Material ------- ______________ <br /> Distance to nearest;`Well -__-._ _._-__-- -Foundationµ —:t _-__-_-._---"" Property Line ` <br /> ry y/ �i <br /> SE=EPAGE PIT Depth -----��- / Diamettee�rI _-_ Numbe; --------__/------------- Rock Filled Yes ®' No 0 <br /> 1 Water Table Depth ___•+-_'- _Z __ �_ _ <br /> p •` • '- ------------------Rack Size ---•--�,-_��------------•- <br /> ( I � IS I <br /> REPAI ADDITION rev. Sanitation <br /> to nearest: Well _____._-_- moi__-- -------------Foundation ___________________ Prop. Line ___-______---..___.._. <br /> Di <br /> Permit# -------------------` ''_' j--------- Date ---------------------------------- <br /> S <br /> -------------------- -----} <br /> it •:. ..'�-_.,...�.....,. _4 ?� } Q <br /> Septic Tan c {Specify Requirements) _ __ � ' [------------- <br /> Disposal Field (Specify)I Requirements] ------------------------ --- �' <br /> I; I <br /> a <br /> ---------------------------------- --- <br /> - .y,_ - - - <br /> {Draw a "sting and required addition onn reverse s de]�_� <br /> I hereby certify that 1 have prepared this application and .that the work will!be done in accordance with San Joaquin <br /> .oun#y Ordinances, State"Laws, and Rules and Regulationslof the San Joaquin Local Health District. Home owner or licen- <br /> `ed agents signature certifies the following: r <br /> it certify that in the performance of the'work for which this permit is issued, I shall not employ any person in such manner <br /> Is to become subject to Workman's Compenaati.on laws of California." <br /> f <br /> gned - ----�j------- -------- -- ------------------------- Owner r <br /> ¢ f `� <br /> Title --------------- <br /> -- <br /> t I <br /> (Ifother than owner) <br /> JeI FOR DEPARTMENT USE ONLY p <br /> '}'PLICATION ACCEPTED;f 7 # DATE __/�-7z---- ------------------- <br /> BY ---- --- ---------------------- --------------- <br /> (ILDING PERMIT ISSUED ----------------------- ------=------ , -------{-------- =: --------------------------DATE -------=----------------- -----------.----- <br /> )DITIONAl COMMENTS Fi f? /: / -` ± '1` <br /> --- ----------------------------------- <br /> //- 7/ /-��,%l' X�S_-`----.� - ------------ <br /> ---: <br /> ---- - --------- <br /> --------- '° t <br /> i c <br /> - ---------------- <br /> tiI Inspection bY: ---_.e_<�------------------ ------------------------ --------------------------Date _-- `:---- <br /> 4 ; SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> j . <br /> 4 4 <br /> ,/. 9 1-'68 Rev. 5M <br />