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ti <br /> FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> Permit No.. --- ----------------- <br /> --- -- --- ------- - <br /> ------- (Complete in Triplicate <br />,. <br /> _ _ p Date Issued <br /> E This Permit Expires 1 Year From Date Issued <br /> I <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein <br /> de549 and existing Rules and Regulations: <br /> cribed. This application is made in compliance with County Ordinance No. <br /> y CENSUS TRACT ---------------•---------- <br /> i -- <br /> JOB ADDRESS/LOCATION fir -I------ ` 3 ��Y <br /> ' __Phone -- -- <br /> Owner's N - - -- ----- - ------------------------------------ <br /> ------------------------------------------------ <br /> � <br /> Address ----�]r ........ +� ti?.. 1------- 1 City <br /> Contractors Name -------.License Phone O� <br /> Installation will serve: Residence [Apartment House❑ Commercial :❑Trailer Court ',E]' i <br /> Motel ❑Other ----------------- -------------------------- <br /> Number of living units:_.____---- Number of bedrooms __ Garbage Grinder ------------ Lot Size -------------------------------------------- <br /> -------------------------- - - <br /> Private ' <br /> Water Supply: Public System and name ------------------------------------------------------------------------------ <br /> + Clay Loam. <br /> Character of soil to a depth of 3 feet-. Sand'j F Silt❑ Clay ❑ Peat❑" Sandy LoahS-❑ Y' ❑ <br /> M _ <br /> Hardpan ❑ Adobe ❑ "'Fill Material ------------ If yes, type ---------------------------- <br /> k (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 SEPT{C TANK'[ ] Size--------------------------------------- --"-- - Liquid Depth -----------=--------•---- � <br /> I Compartments -------------•--- <br /> Capacity --------------------- Type ------------ ------ Material----- ----------- P <br /> Distance to nearest: Well "------------ ---------------- <br /> Foundation ----- -------------- Prop. Line ------------- -------- <br /> .. Tota! Length -- ----------------•-------- <br /> LEACHING LINE [ ] No. of Lines __--------------------- Lengt of each line------------------------- - <br /> --Depth Filter M terial -------------------------------------- <br /> 'D' Box,----- ------ Type Filter Materi 1 __.__._----_"""-- <br /> e to nearest: We ------"-- <br /> --" _ ------- Foundation ------ Property Line <br /> Depth .I --- ��--------- Number -------------------- ------ Rock Filled Yes ❑ No .i❑ <br /> Distant <br /> SEEPAGE PIT Diameter <br /> [ ] P <br /> ----------- --- -`- --------- ------ Rock Size <br /> Water Table Depth ----------------------- <br /> ! <br /> Foundation -- ----------------- Prop. Line --------------•------ <br /> Distance to nearest: Well -------- -------------------____ __ _ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ---------------- <br /> Date -------------- -- ----------------1 " .. <br /> ---------- --------- <br /> ents} -------- ----------------- ------------------------------------------------------ <br /> Septic Tank {Specify Requirem . <br /> Disp sal Field (Specify Requirements) - <br /> Dig <br /> .c - -------- am -� --------- ------ <br /> -_- - - <br /> ------------------------------- - <br /> --------------------- <br /> (Draw existing and required addition on reverse side) <br /> ared thiswork will be <br /> ace <br /> n Joaquin <br /> ne <br /> 1 hereby certify that I have prep Joaquin Rules ppl'Regulationscation and taat the f the San Joaquin LocaloHealth D strrct nHometowsner or 1 cen- <br /> County Ordinances, State Laws, i <br /> sed agents signature certifies the following: <br /> "I certify that in the performance of the work for which this permit is issues,:l shall not employ any person in such manner <br /> as to become subject to Work_ an's Compensation laws of California." <br /> Signed -----------_ Owner <br /> ------- -------- -- ------ <br /> ---- --- - -- - -------- ----- <br /> Title - ------------- -------------- - ---------- --------------------------- <br /> (If other than owner) <br /> I FOR DEPARTMENT USE ONLY <br /> DATE ------L�`I 'f�---------- <br /> APPLICATI�� SY :_____ :_­_'_,_.0'_h_11 "--v= ------ ----"""-" - <br /> BUILDING PERMIT ISSUED ----------------------- - -------------- <br /> ---- --------- ------------- DATE - <br /> ADDITIONAL <br /> k COMMENTS ------�---- ----------- ---------------------------------------------- <br /> -------- --------------------------------------- -------------------- <br /> ------------------- <br /> ------------- <br /> ------------ <br /> ----------------------- --------------------- --------------------------------------------------- <br /> _ ---------------- - ------------------ --------- ---------------------------------------: ---- <br /> --------- <br /> ------------ <br /> ---- ---------- t = - v_ _ Date ---- 3 --------- <br /> ------------ <br /> ----------------------------------------- <br /> Final -- <br /> `{nspection bY: ---------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />