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P <br /> FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> (Completein Triplicate) Permit No. <br /> ---------- ------------------------- <br /> This Permit Expires 1 Year From Date Issued 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 County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION ------- OSQ-I--------- Lau_Kf0---go------------- ---------------- -----CENSUS TRACT ---- --.----------- <br /> Owner's Name 0,5 din14 `� A�-4lC-- ------------------------------- ------------ Phone.- �__`�Q-�---------- <br /> Address --------------------- f11_�S1.�Q---Ri----------------- ------------ City -------IRky--------------------------------------------------------- <br /> Contractor's Name -------------------QWNf2-----------------------------------------------------License # --- -:-------�--- Phone -------``----------------- <br /> 4 Installation will serve: Residence *partment House-E] Commercial ❑Trailer Court ;❑ <br /> r Motel E] Other -------------------------------------------- <br /> Number of living units:.--_I-___-- Number of bedrooms __A1____-Garbage Grinder - ------ Lot Size ---8 __X_1-36P_________________ <br /> Water Supply: Public System and name ---------------------------------•----------------------------------------------------------------------------Private <br /> Character of soil to a depth of 3 feet: Sand'[] Silt F1 Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe ❑ Fill Material ------------ 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 feet,) O��,,��ii .. 0 <br /> PACKAGE TREATMENT [ ] SEPTIC TANK'[ �n7 Size--_____&x_ X6- _-44 <br /> � _ ------------------- Liquid Depth . __-.________ Q <br /> Capacity _.� �_--_.. Type -Po Cil----. MaterialCbnGMAA------- No. Compartments ----?-------------- <br /> Distance to near��el1st: Well ------___-50--------------------Foundation --____1U------.___ Prop. Line ------6------ __.._. <br /> LEACHING LINE [ ] No. of Lines ____=:1__--------------- Length of each line-------- U-------------- Total Length ......... <br /> 'D' Box __ ----- Type Filter Material ,_f`QC-------Depth Filter Material _______l -------- --------I—........... <br /> Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line _______._.__-___..------ <br /> SEEPAGE <br /> _._ _SEEPAGE PIT [ ] 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 to Workman's Compensation laws of California." <br /> Signed ----------------------------------------- Owner <br /> f BY' Title - --------------------------- - - <br /> ---------- <br /> 8 (I--ler t an owner) <br /> FOR DEPARTMENT USE LY <br /> APPLICATION ACCEPTED BY --------------------------=- DATE --b�= r <br /> BUILDING PERMIT ISSUED . �-------- --- ---- ------DATE ------- ------------------------ ---------- <br /> ADDITIONAL COMMENTS -------------------- <br /> -------------------------------------------------------------------------------------------6- <br /> ------------------------- <br /> -------------------------------------------------------------------- --------------------------------------------------------------.N------------------------------------------------------------------- <br /> ------------------------------------------------------------------------------------------------------------- ----------- - <br /> ---- -- --- -------- ---- <br /> Final Inspection by; ----------------------------------------------------------------------------- ---- ------.Date --- -A� ---------------------- <br /> k SAN JOAQUIN LOCAL HEALTH TRICT <br /> E. H. 9 1-'68 Rev. 5M co <br />