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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT q <br /> Permit No. /--`-.- �/ <br /> -- - -- ------------------=------------------------------ <br /> ' - - (Complete in Triplicate) <br /> -------------------- <br /> -------- --------- Date issued ..... <br /> This Permit Expires 1 Year From Date Issued <br /> ---------- 4 <br /> rict <br /> it to construct and <br /> e work herein <br /> Application is hereby made to the San Joaquin Local Health compliance with CounDtytO Ordinance a Nom549 and e i t ng Rules tand hRegulat ons- <br /> described.,This, com.application_.is. ade �n p <br /> r �!�►�j_n1-�1 ..�,.�l S 0 LSI r f <br /> /tel CE S TRACT } <br /> JOB ADDRESS/LOCATION ��--- <br /> ------------------------- ---- Ar'---Phone ---------------------------- <br /> -4 - - ------------------ i✓i <br /> Owner's Name --- - -}�F--- � ------------ - <br /> Address _ - -- ---- --------- <br /> City <br /> --.- � one <br /> - ---- ---- -- <br /> i. - -- <br /> Contractor's Name -- -- ------ -- --- <br /> - -------License Ph <br /> Installation will serve: Residence Apartment House'❑ Commercial :[]Trailer Court <br /> Motel ❑Other -------=--------- -------------------------- <br /> Number of living units------ Nurfiloer,of bedrooms ___ _____Garbage Grinder --- -------- Lofi Size _____________ -- --- <br /> Private , <br /> �. ------- -- - = d <br /> Water Supply: Public System and name .P°`_____-____ <br /> ' t .Peat❑ Sand Loam �- Cay,--LoamCharacter of soil to a depth of 3 feet: SandSilt❑ Gay ❑ y <br /> MHardpan ❑ Adobe'❑ Fill Material ------------ If Yes,type ------------- <br /> Plot Ian; showing size of blot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) .� <br /> ( P <br /> r seepage pi perm--itted if public sewer is available within 200 feet,) <br /> NEW INSTALLATION: (No septic tank o <br /> S- ze------------------ =- -"----------- <br /> --a------- Liquid <br /> Depth ----------------- - <br /> PACKAGE,TREATMENT SEPTIC TANK [ 7` , _ NoCartments -----------------. <br /> ----- <br /> R---- ----Capacity -------- Type - _ I f <br /> = ----------------------Foundation ' ------------------- Prop. Line ---------------------- <br /> f.. Distance to nearest: Well ______________ <br /> 1 <br /> 11 <br /> { ___::7-:-Total�,Length <br /> Noof Lines ---------------- Length of each line---------------- <br /> LEACHING <br /> LINE [ i <br /> De th Filter Materiai� == `-------------------------- --------- <br /> 'D' Box .! -------- Type Filter Materia{ ----------------- p . <br /> Distance to nearest: Well --------------------�_Foundation ----- Property Line ---------- ------------- <br /> Depth t Diameter Number --------------------- Rock Filled Yes '[] No .[3 <br /> SEEPAGE PIT [ ) t De P ' ---------- -- <br /> 'Water Table Depth ----" <br /> ---------------------------------._Rock Size <br /> t t-- .. .-.---Foundation -------------------- Prop. Line -------------• ------- <br /> Distance to nearest: Wel.i -----_-------------_________ ______ <br /> I <br /> ' -------- -------- -- Date ---------------------------------- <br /> REPAIR/ADDITION(P,r°ev. Sanitation Permit# -------- ------------ <br /> h i I ----------- ------------ ----------- <br /> - --------------------------- -- <br /> Septic Tank (Specify Requirements) ------------------------------ -------------------"------ ---- <br /> 4­64W—nig- <br /> Disposal Field (Specif Requirements) -------- <br /> -a t - <br /> ---------------------------------------------------------------------E <br /> --- -`---- I----------- ------------------------------------------------------- <br /> = <br /> { (Draw existing and-required addition on reverse s�)___ ��-- <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 be a subject to Workman's Compensation laws of California." <br /> Signed -_ ' Owner <br /> ----------- ----------------- <br /> ' Title ------------- <br /> _ _ _ _ -- <br /> By (if other than owned <br /> FORDEPA1tTMENT USE ONLY <br /> lr�' DATE '"_ ---------------- <br /> APPLICATION ACCEPTED BY'-- --- - ----------- ---- <br /> -- -- - - - - --------------------- <br /> BUILDING PERMIT ISSUED ----------------------------------------------------------------------------------------------------------------- <br /> ------- DAT ------------------------------------------ <br /> BUILDING <br /> ---------- -------- -------------•---- <br /> ADDITIONAL COMMENTS ----------------------------------------------------=------ <br /> -------------------------- <br /> ----------- _------------------ -_---_----------- --------- ---- - �- � ---- ---" -------- <br /> __ _ - _ _ <br /> --------------------------- <br /> -Date <br /> Final Inspection by: ._ �-- -------�""""--"� -�- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M __ <br />