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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT - <br /> � --=------ ------- - <br /> (Complete in Triplicate) Permit No; <br /> __________--------------- This Permit Expires 1 Year From pate Issued Date Issued __-_9_` : <br /> Application is'hereby made to the San Joaquin Local Health District for a per to"construct and install the work herein <br /> described._This application is made in compliance with Cou ty Ordinance No.,549 and°existing Rules and Regulations. <br /> � � � _ CENSUS TR <br /> JOB ADDRESS/LOCATION _ -- ------ --- - W `---�.�._.� U ACTe..._. " -------- <br /> Owner's Name - - -- -------- ----------------- ----- - ~Phone <br /> �� � <br /> Address ---- ------------------ 7 - - ------------------- CitY '---------------------------------- <br /> Contractor's <br /> ---------- ------------------ <br /> Contractor's Name --------------- ---- --- i,- • -- - -------------- ---------•---------.License #�-- --------�---- Phone <br /> Installation will serve: Residence ❑Apartment House❑ Commercial ;❑Trailer Court i❑ <br /> 'J. <br /> ;�- Motel ❑ Other---------------------------------�---------- <br /> Number of living units ..... Nurriber'of�bedrooms __5______Garbage Grinder ___________ Lot Size _.___ _ _______ __________________ <br /> Water Supply: Public System and name °,;- ` - -------------- - ------------- ----------------------Private <br /> Character of soil to a depth of 3 feet: Sandi Silt❑ Clay ❑ Peat❑ Sandy Loam 0 Clay Loam '❑ <br /> % :- t Y.; <br /> Hardpan ❑ AdobeW' ill Material ____._______ If yes,type ---------------------------- <br /> 1 it <br /> (Plot plan, showing size of lot, location of system in relation t 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 /> t <br /> PACKAGE TREATMENT [ ] SEPTIC TANK 1[ ] Size____________________ ____________ i <br /> ________ ______• Liquid .Depth ________________•___,____. i <br /> Capacity ---------------- --- Type Material'- , No;.Compartments = <br /> { ,� , <br /> Distance to,lnearest:, Well ----- t------------.------------- FoLmdat o -k_- -- ------- ---Prop. Line ---------------------- <br /> LEACHING LINT: [ ] No. of Lines -'------ ------------ length of each line-------------�- -�--_---Notal Length ------------------- -------- <br /> 'D' Box ----------Type Filter Matehal --------------------Depth Filter Material ---------'-------.---------------------- <br /> :,... r <br /> I . <br /> Distance to nearest: Well ------------I----------- Foundation ------------------------ Property Line. ____---_._.______----.-- <br /> SEEPAGE PIT [ ] Depth ____.__J_._______1 Diameter ___ ----------- Number __ ______ _ _ _ _ _________ Rock Filled Yes ❑ No C] <br /> Water Table Depth --------------------- i----------------------.-Rock Size ------------------------- <br /> Distance to nearest: Well _______ ------------------- ---------------------------------_____ -•Foundation ______ __ ________ Prop. Line.___________________•__ <br /> REPAIR/ADDITION(Prev.Sanitation Permit#---------------I-__.___I____________________ Date ---------------------------------I <br /> i - _ <br /> Septic Tank [Specify Requirements] - I I4 i <br /> ---------•--- ------ <br /> Disposal Field (Specify Requirements) `! <br /> -------------- - - �- ��_- - - ------ ----------- - <br /> =- _ <br /> ---- ----------------------------- ------------------------------- ----------- -- ----- ---------=--------------------I---------------- ------------------- I------- - <br /> {Drav✓eztisting and requked addition on reverse side) <br /> 1 hereby certify that 1 have prepared this;application and that the work will i 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: y <br /> "I! certify that in the performance of the work for whiL this p ermit is issued, I shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> a—� ` i Owner <br /> Signed _ --------- <br /> E k <br /> BY - - ------------------ ------ Title --------------- -- <br /> {If othe an owner] <br /> FOR'DEPA1tTNiENT USE ONLY <br /> APPLICATION ACCEPTED BY -- ---------------------------------------------------------, DATE -e __76j-_---------------- i <br /> BUILDING PERMIT ISSUED ------------------------------------------------------------------------)------------------=--------------DATE ------------------------------------------- <br /> ADDiTIONAL COMMENTS ------------------------------------------------- A1------------------------------ <br /> -----------------­ -------------- ----------- ------------------------ ------------------------------------------------ <br /> c <br /> __ t _ - p L___________ <br /> Final Inspection by: - Date ---- ----------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> k <br /> E. H. 9 1-'68 Rev. 5M, <br />