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a acv I S C4 /le <br /> FOR OFFICE USE: I <br /> APPLICATION FOR SANITATION PERMIT <br /> �� (Complete in Triplicate) Permit No. <br /> - <br /> ------------------------------------------------------- <br /> Date Issued <br /> ---------- ----------------------- --- ----------- This Permit Expires 1 Year From Date Issued <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 issmade in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION .-llv.S-_�C.1_-- ------`--- - ,LI 'tl1- --------------------------------------._CENSUS TRACT -------------- ........... <br /> Name -------I`+ �;---je�'�6�-------------------------------------------------=- -------Phone <br /> Address ------ - Gra-O- --4_6�---�i>_ Cit 77 --- !-l'- --------------------•------ <br /> �f �` Y <br /> Contractor's Name __14-__/-------- (� ^_2 -__-_.License #pZ_7 --------�___-�_ Phone -_______------------------- <br /> Installation will serve: Residence partment House❑ Commercial [-]Trailer Court i❑ <br /> Motel ❑Other ___. ______________________ r <br /> Number of living units:--- <br /> /---- Number of bedrooms _/--------Garbage Grinder ------------ Lot Size 0,1 - 7�- ._.. <br /> Water Supply: Public System and name .-----6-T-Kc------------------------------------------------------------------ -------------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam <br /> Hardpan ❑ Adobe ❑ Fill Material ------------ If yes,type ---------------------------- <br /> (Plot <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 i�available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size__6____T-------;57------------------- Liquid Depth -------or.Q............. <br /> Capacity ..� ,___ Type fP�-_ _C�sTMaterial---------------------- Na Compartments __._�.�............. <br /> Distance to nearest: Well __--------------------------------Foundation _4Q___--_-_____ Prop. Line --_-�?`!-•,.--:-_ <br /> LEACHING LINE [ ] No. of Lines _____ _______________ Length of each line--------`�__ll_____-_.____ Total Length ---------________________ <br /> 'D' Box ___________ Type Filter Material ____________________Depth Filter Material -------------------------------------------- <br /> Distance <br /> __--_-----_______--______-_-_-_- .__----Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line ....................... <br /> SEEPAGE PIT [ J Depth -------------------- Diameter ---------------- Number ____________________________ Rock Filled Yes ❑ No i❑ ` <br /> Water Table Depth ------------------------------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well ________________________________________Foundation -------------------- Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) <br /> SepticTank (Specify Requirements) --- ------------------------------------------------------------------ ---------------------- -----•-------------------- <br /> Disposal Field (Specify Requirements) -____-_-__-_ ______________ <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 subject W man' mpensation laws of California." <br /> Signed -- ---------------------- ---- Owner <br /> BY ----------------------- --------------------------------- --------------------------------------------- Title ------------------------------------------- ---------------------------- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ------------------------------------- r® h-------------. DATE ----$ - -".*?- <br /> PERMIT ISSUED ---------- DATE <br /> ---------- ----- ---------------------------- <br /> ADDITIONALCOMMENTS ----------------------------------------------------------------------------------------------------- <br /> ------------------------------------------------•--------------------------------------------------------------- ---------------------- ---------------------------------------------- ------------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ------------------------------- ------------------------------------------------ -------------------------------------------- ---------_--_----------- ----------------- <br /> -------------------------------- <br /> Final <br /> Ins ection by: T ----- ----------------------- <br /> -------- <br /> SAN JOAQUIN LOCAL HEALTH (STRICT <br /> E. H. 9 1-'68 Rev. 5M <br />