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�- - FOR OFFICE USE: APPLICATION FOR SANITATION PcRMIT <br /> - --- ------ ---------- ----•--- -------------- Permit No. <br /> + <br /> ---------=------------------------------------------ p <br /> ' (Complete in Triplicate) <br /> Date Issued ��l_"_?o <br /> - This Permit Expires ii 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 is made in compliance with Coun y Ordinance No. 549 and existing Rules an egulations: <br /> JOB ADDRESS/LOCATION -4- -- ----.. -,F"- CENSUS TRACT S if <br /> Owner's Name . p Phone <br /> Address �� ' r '-- ---- -0-Ad----•--- City ------- 1�!- --------------------------------------- <br /> G <br /> Contractor's Name ---64iV j� <br /> It- #�-fit-�. �_-- Phone <br /> // <br /> Installation will serve: Residence[Apartment House-[] Commercial ❑Trailer Court ;❑ <br /> Motel ❑Other ---- ------------------------------------- <br /> Number of living units------------- Number of bedrooms -.�-----Garbage Grinder ------------ Lot Size -- _-- ��----f------------------- <br /> Water Supply: Public System and name --------------------------------------------------------------I-------------------------I------------ ---------Private IX <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 -__-----t---_-------- <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed 6n reverse side.) \ <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) (1� <br /> PACKAGE TREATMENT [ } SEPTIC TANK:[ ] Size------------------------------------ Liquid Depth -------------------------- <br /> Capacity --------- ---------- Type -------------------- Material-------------------- No. Compartments L4 <br /> Distance to nearest: Well -------------------------------------Foundation --------- :-------- Prop. Line ----------- ------ <br /> LEACHING LINE [ ] No. of Lines ------------------------ Length'°of each line.___---1 _- -.____J 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 ❑ No i[] <br /> WaterTable Depth ------------------------------------------------Rock Size -------------------------------- <br /> Distance <br /> ------------ -- -- <br /> Distance to nearest: Well ----------------------------------------Foundation ----- ------ ---- Prop. Line _-_-----__.-...___--- ' <br /> RIEPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ------..----------.------- -----) <br /> SepticTank (Specify Requirements) ----- -----------------------------I------------------------ ----------------------•--------- ------------- -------------------------------- <br /> Disposal Field (Specify Requirements) « f ---------/----6-----a Ei b----------I / --------------------- <br /> ------------------o-W-Z------ � -------5__aE_F rr'N-'-------P-1-7------------------------------------------------------------------------------ <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 Jou+ <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or lit <br /> 4 <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 mant <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed -------------------------------------------------------------------------- ---------------------- Owner <br /> 0 <br /> BY Y-� =.'(/11---------------------------------------- Title --- <br /> (If other than own ) <br /> FOR DEPARTMENT USE ONLY = <br /> APPLICATION ACCEPTED BY __ __ ------------------------------------------------------------ DATE _,S`-_7-- a---------------4 <br /> BUILDINGPERMIT ISSUED -------------------- ---------------------------------------------------------------------- --------------DATE --------------------------------------------------- <br /> ADDITIONAL <br /> --------------------------------- -- - <br /> ADDITIONALCOMMENTS --------------- --------------------------------------------------------------- ---------------------------------------------------------------- <br /> ---------------------------•------------- t------------------------------------------------------- ------ ------------------------------------------------------- ----- <br /> ------------------------------ ------------------- --z_4 <br /> - --_ d----------------------------------------------------------------------------------- - <br /> - _ )� <br /> ------.Date . -- <br /> -- 4 <br /> Final Inspection by: - --- -�_'�`����'c. - - -------------- ---------- <br /> SAN <br /> ---- - - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />