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F'° FEcICE ]JSE: APPLICATION- FOR SANITATION PERMIT _Z, <br /> , --------_�T-- ---- - r. Permit No 7.2` 17 <br /> - -7` (Complete in Triplicate) - <br /> --------------------------------------------- 73 ' <br /> f Date Issued __ 3-.___. <br /> -------------------------------------------}------------ This Permit Expires 1 Year from Date Issued <br /> t <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 /> JOB ADDRESS/LOCATION .----..--° _-- --7 ------------- ----------+---.--.CENSUS TRACT -------------------------- <br /> s� <br /> Owner's Name .,-.-/- 7--- --------- -------------------------- -------- ---------- - Phone 5 '-0-_S-,_r <br /> Address6� / -------------------------------------------- City ------- -----•--- <br /> Contrtactor's Name = ------------------------------------------------------------License # ----- ---:-------------- Phone -------- .................. <br /> Installation will serve Residences[Apartment House❑ Commercial:[]Trailer Court ;❑ <br /> ► t Motel ❑ Other -------------------------------------------- a <br /> Number of living unix s:-;-1------ Number of bedrooms ---------Garbage Grinder ----- -- _ Lot Size _._ _-_Q__-_X____�__ __ ------ <br /> Water Supply:—Public System and name ________� ______W- A1`t.____________.________'____-_---____-------------------Private ❑ <br /> A � <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam E] Clay Loam E] <br /> Hardpan E$( Adobe ��� Fill Material _________ If yes,type ---------------------------- <br /> ° t <br /> N <br /> {Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) (� <br /> PACKAGE TREATMENT [ SEPTIC TANK [ ] Size__ --------------------------------- __.__.____ Liquid Depth -------------------------- <br /> Capacityo2�!70_0__�S�'Ype ---jiO � Materia �s_- �_ No. Compartments _____________ __ _ <br /> ( Distance to nearest: Well ------ --------------------Foundation --------------------- Prop. Line ---------------------- <br /> LEACHING <br /> ____-_____..._._LEACHING LINE [ ] No. of Lin s ------------------------ Length of each line _______ ________ Total Length ------.-___.---------------- <br /> € - <br /> > <br /> 'D' Box ----1----.- Type Filter Material --------------------Depth Filter! Material -------------------------------------------- <br /> Di sto nce-to4nea rest: <br /> -------------------------------------------Distance-toinearest:=Well - =----_=-- Foundations==- -; ----------- Property Lige.._-:'------------------•- <br /> -SEEPAGE PIT [ ] Depth e Diameter ________________ Number ---------------------------- Rock Filled Yes�$( No i❑ <br /> A _ <br /> Water Table Depth ------------------------------------------------Rock Size ---------------------------- -� <br /> I / <br /> Distance to nearest: Well _____________________Foundation I.�`____._____.---- Prop. Line'd=...__j---------------- <br /> t r � <br /> REPAIR/ADDITION-(-Prev..,-Sanitation Permit# ------------------------------------------- Date ________________________-_______--) L <br /> Septic Tank (Specify Requirements) -------------------- ---------------•---------------------------------------------------------------- - _g-------------------- <br /> Field.,(Spe fy RequirmI ------Disp arr � <br /> - r <br /> � lrl4--� �-------r X <br /> ---- --� �1 ( �YIfi!v- 1� tn"------ t �'P <br /> 1�-- $ <br /> (Draw existing an required a ition on rev si( e) <br /> I hereby certify that I have prepared this application and that the work will be done in:accordance with San Joaquin <br /> County Ordirnances,fState 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`subiect to Workman's Compensation laws of California." , <br /> t r <br /> Signed ------ -� ---------------------------------- Owner <br /> BY -------- -------------'------ ------------------------'----------- ------------------------------------ Title ------------- <br /> (If other than owner) <br /> "FOPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ----- - ---- -- -------------------------------------------------------- DATE __ ------------------- <br /> BUILDING PERMIT ISSUED ------ DATE -------------• --=------------------------ <br /> ADDITIONAL COMMENTS ----- -- ----- ---- - - - - ------ -----------------------------------------------------------------------------------------=---- , <br /> ------------------- -------=--------------- ------ ----------------------------------------------------------------------- <br /> p y <br /> --------------------------------------- -- - -- - -- - ----------------------------------------------------------- -- ---------------------- ----------------------- ------ E <br /> Final Inspection b -- - ---- - - -- - - ----------- -------- ----'=---------------------- --------- ---------------------Date����`__'.=�-��-- ---------- <br /> I „. F <br /> SAM JOAQUIN �LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />