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r FOR OFFICE USE: y <br /> APPLICATION FOR SANITATION PERMIT [ <br /> - --- --- - -- ------- -------------- <br /> (Complete in Triplicate) Permit No: <br /> ---------=----------------------------------------------- <br /> _________________________________________________________ This Permit Expires 1 Year From Date Issued <br /> 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 /> X253�(r�r� -0s ,� <br /> JOB ADDRESS/LOCATION . - _ ._...----CENSUS TRACT <br /> Owner's Name ----/2/_c_h-lgr?i�------ - C_h Phone <br /> ,�,- ---------------------- ----- <br /> Address . c r_/?L1YYI_ ZS-lG,✓ _. City � �r ---- <br /> - ---------•-------------- <br /> Contractor's Name -- --_ _____.License # - �� cF `� <br /> t-Y �- �J��,/��--------------------------=- � -- -- Phone - ---------.� <br /> Installation will serve: Residence N'Apartment House❑ Commercial ❑Trailer Court ❑ <br /> Motel ❑/- Other -------------------------------------------- g�� <br /> Number of living units:----_ ---- Number of bedrooms ��_-----Garba_ge Grinder ----------- Lot Size _��_C7 A;__ j`___ ---------•--- ' <br /> Water Supply: Public System and name ------------------------------------ ----- ----------------------------------------------------------------Private,[ <br /> Character.of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam :❑ + <br /> Hardpan ❑ Adobe �9 Fill Material ------------ If yes, type ---------------------------- �R <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) �4 <br /> NEW INSTALLATION: <br /> {No septic tank or seepage pit permitted if public sewer is available within 200 feet,) � � <br /> PACKAGE TREATMENT f ] SEPTIC TANK'[ ] Size----�zk___ X24__ _6__-__.___ Liquid Depth j�___ ______,_____ <br /> Capacity � 6.6- Type _�-�� Material__ No. Compartments _-------------........ <br /> Distance to nearest: Well ---._7D--- ----------------Foundation _.__/_._______..... Prop. Line t?_________:________ <br /> LEACHING LINE [ ] No. of Lines __ ______ _ _______ Length of each line------/_ ------------ Total Length s;?20--------------- <br /> i /y <br /> D' Box _____ __ Type Filter MaterialfZ�___Depth Filter Material � ____________________________-____._ <br /> f <br /> Distance to nearest: Well -----4� _/_______ Foundation -----/__O__-------- Property Line b_____________________ M <br /> SEEPAGE PIT [ ] Depth _.__. -------------- Diameter ________________ Number ---------------------------- Rock Filled Yes 0 No 0 � <br /> V% <br /> WaterTable Depth ------------------------------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well ----------------------------------------Foundation --------------------- Prop. Line ............-......... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) <br /> SepticTank (Specify Requirements) -----------------------------------------------------------------------------------------------:---------------------------------------------- <br /> Disposai Field (Specify Requirements) ----------------------------------------------------------------------------- <br /> ----------­--------- <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 Comeensati.on laws of California." <br /> Signed <br /> � Owner <br /> ---------------------------- <br /> By <br /> --------------------------BY ---1-- ------- Title ------------------------------- --------- ---------------------------- <br /> i <br /> (If other than owner) - - FOR k <br /> DEPARTMENT USE ONLY <br /> ACCEPTEDBY - --- - - ----------------------------------------------------------------------------------------- DATE ----------------------- ------------------ <br /> BUILDING PERMIT ISSUED --------------------------------- ------------------- <br /> - <br /> -------------------- ---------------_------- -----DATE ------------- ------------------ - - -•--- <br /> --- <br /> ADDITIONALCOMMENTS ------------------------------------------------------------------- ------------------------------------------------ -------- ------------------ <br /> ------------------------------------- <br /> - ------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> Final Inspection ection -- - ------------------------------------- -------------------------- ------------------ a 3----------_-_-_--- <br /> -- - - <br /> - - --- -- - - -- -- <br /> p Y ---Date <br /> SAN JOAQUIN LOCAL HEA T DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />