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My <br /> FOR,!OFFICE USE: <br /> APPLICATION'_FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit No. <br /> - ------------ <br /> ---------------------------------------------------------- <br /> ------------------------------------------------------ This Permit Expires 1 Year From Date Issued Date Issued <br /> lk <br /> Application is hereby madeo-T e San Joaq_uin' Local Health District and install the work herein <br /> des.cribed. This app�fiion is made in compliance with County Ordinance No. 549--an xis Rules and Regulations: <br /> N <br /> JOB ADDRESS/LO ATION --------- R ---- CENSUS TR CT --------------------_--- <br /> Owner's Name ---- -- --/JV_,70,_A/ <br /> ------------ ------- ----------- --- --- e --- --- <br /> 9----------------I------ <br /> Address -- ------ ----- --------------- Se y V <br /> -- -- -- ------- _/4_�- -----------_ Cit W <br /> Contractor's Name -- - -- -- -- ______.License #c:2$/ Phone <br /> Installation will serve: Residence E]A rtment House,0 Commercial;[]Trailer Court <br /> Motel [:]Other -------------------- <br /> Number of living units:___._-___-- Number of bedrooms _,,,:?.__--Garbage Grinder ------------ Lot Size ___________________ <br /> Water Supply. Public System.and name ---------------------------------------------------------------------------------------------------------------- <br /> -Private El <br /> Character of soil to a depth of 3 feet; Sand [] Sift❑ Clay -9 Peat❑ Sandy Loam Clay-Loam ,[] <br /> Hardpan Ej Adobe'[] Fill Mate-n—al-7�_-If yes, type—--------- <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 feetj <br /> PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] Size_____________________________________ ____ _____ Liquid Depth .... ............... <br /> Capacity --------- ---------- Type -------------------- Material---- ----------------- No. -Compartments -------------- <br /> Distance to nearest. Well -------------------------------•---.Foundation ---------------------- Prop, Line ...................... <br /> LEACHING LINE No. of Lines ------------------------ Length of each line-____________________---___- Total Length ------------- --------------- <br /> 'D' Box ------------ Type Filter Material --------------------Depth Filter Material --------------------------1------------- <br /> Distance to-,nearest: WellFounclaflon Property-Line <br /> ------------- ------------ ­. ------ <br /> SEEPAGE PIT Depth -------------------- Diameter ---------------. Number,--------------------------- Rock Filled Yes C] No C] <br /> Water Table Depth ----------------------- ------------------------Rock Size ------------------------ <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ------------------ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ------------------------- ------------------ Date -_______________-________________I i Tank (Specify Requirements) ------ ------------7------ ----- ---- - ------------:---------- <br /> Disposal Field (Specify Requirements) - --------- -------- <br /> e------ <br /> 130 - ----------- ----- ------- <br /> NI: <br /> --------------------------- ----------------------------------------------/-- ---------:--------------------------------------------------------------------------------------- <br />- -------- =---------------------------------- <br /> -- -----------------------------------------------------------(Draw existing and required addition 66—reverse siide)---- <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ord'inances, 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 subi4ct to Workman's Compensation laws,of California." <br /> Signed- -- ------ ----------------------- Owner <br /> By ----- ------ <br /> - - -------------- ------------- <br /> Title ------z-------------------------------------------------- -------------- <br /> (ff other an owner) <br /> FOR DEPARTMENT USE O/NLY <br /> APPLICATION ACCEPTED BY <br /> ------------------------------------------------ ------ ---------------------------------- DATE ---------------------------------- <br /> BUILDING PERMIT ISSUED --------- <br /> ­--------------------------------------:-------------� ------- -------------------------------------DATE -- ---------------------------------------- <br /> ADDITIONAL COMMENTS ------------ <br /> ------------ --------------------------------------------------------------------------------------------- --/__�- - - - - ---------------------- - - ---:------- <br /> ------------------------------------------------- ---------------------------------------------------- --- --- - - ------------ ---------------- ------------------------- <br /> -------------------------------------------------------- <br /> ------------------------- <br /> Final Inspection by: -------------------------------------------------------------------- --d-------------------------------- -----------�)_9------- ------------------- <br /> ------ <br /> Final -----------.Date --------------------------------------- <br /> SAN JOAQUIN LO AL ALTH DISTRICT 3. <br /> E. H. 9 1-'68 Rev. 5M, <br />