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FOR OFFICE USES APPLICATION FOR SANITATION PERMIT <br /> Permit No,. -- _-. <br /> (Complete in Triplicate) <br /> This Permit Expires 1 Year From Date issued <br /> Date Issued <br /> --------------------------------------------------------- <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. 6.49 and existing Rules and Regulations:. <br /> JOB ADDRESS/LOCATION . 2_ - -----(T�ff - <br /> rl �l -E;yCENSUS TRACT ------ <br /> ---- ---- <br /> - - -------PhoneOwners Name = <br /> I <br /> Address J---2-Z-c_r1- ,- ----` �Jv�� ------------------------ City <br /> Contractor's Name �� ----------------=- ---- License # -� 1-I3 Phone > = " <br /> Installation will serve: Residence ['Apartment House❑ Commercial :❑Trailer Court i❑ ... <br /> Yti /xl <br /> Motel ❑Other --------------------------------------------- <br /> Number o'f living units:-,-i------- Number of bedrooms _3------ Grinder Lot Size ----_c F,�)'lx—-------- <br /> I? <br /> Water Supply: Public System and name --------------_------- - <br /> ----- --------------- - ------------•-------------- ----------•----= ---------Private <br /> Character of soil to a depth of 3 feet: Sand' SiI❑ Clay ❑ Peat❑ Sandy Loam •❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe ❑ Fill Material _-1V6__ if yes, type --------_---------------- <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. ust be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within'260,feet,) <br /> PACKAGE TREATMENT [ I SEPTIC TANK 1 I Size---------------------------------------- :quid-D&pth---1 ;_-_-------' <br /> w <br /> Capacity -------------------- Type -------------------- Material---------------------- No. Compartments --------------------- <br /> .Distance <br /> -: 6� <br /> .Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ---------- ------ <br /> LEACHINGLINE ',11:1., No. of Lines ------------------------ Length of each line------------ ------------.-- Total Length ---------------------------- <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 0 No <br /> WaterTable Depth ------------------------------------------------Rock Size -------------------------------- <br /> Distance to nearest. Well ----------------------------------- ---Foundation -------------------- Prop. Line --------------.------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit�# - ---- ------ Date ----------------------------------) <br /> Septic Tank (Specify Requirements) <br /> Di 'pd'sal Field (Specify Requirements) - f /.Q �1 c ',1 �' 1 --------- '� <br /> --L - ¢ � G, �G//C/I ' ---¢--------ll AGU�I?�-------------------------- <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. 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 s7b*e�ctto orkman's compensation laws of California."Signed l�l- Owner <br /> BY ---------------_---------------------------------------------------------------------------- - Title ..-------------- ------- ----------- --------- ----------------------- <br /> (If other than owner) ' <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY --------- ------------------------------------------------------------------- ----- DATE ----�------ <br /> BUILDING PERMIT ISSUED ----------------------------------`-------------------------------- -------.DATE ------------- --------------- ------------- <br /> ADDITIONALCOMMENTS -------- -------- ------------------------------------------------------------------------- --------------------- --------------------------- <br /> -----------------•---------------------- - --- - ---------- ---------------------------------------------------------------------------------------------- <br /> -- ---- --- ---- - - -- -------- ---------- ---- ----- ------- -- <br /> - -------- -- --- - - - -- <br /> Final lnspe � --------------------Date ----- <br /> ------ --------- -- - - -- <br />` SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br /> .t - <br />