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FOR OFFICE USL: <br /> APPLICATION FOR SANITATION PERMIT L <br /> ------- --�--- � --- - Permit No. ..�3="6� <br /> {Complete in Triplicate) <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 /> } 1. <br /> 1 <br /> JOB ADDRESS/LOCATION �t� w <br /> ---------- ------------------------------------------------------------------------------CENSUS TRACT -------------------------- <br /> Owner's Name - - o ---- - ----- ---------------------------- <br /> -----------------------------------------=-I-------------------Phone - ---------------------------------- <br /> ---- <br /> Address -- -------------I <br /> ----.------ ------------------------------. City -"' `z'�y------------------------------------ ----------•--•------ <br /> 1 <br /> Contractor's Name -------•-----'------------0-----------------------------0-----------.License # ------------------------ Phone ----------------------------- <br /> M <br /> Installation will serve: Residence Apartment House Commercial railer Court ;E] <br /> 1 Motel ❑Other ------------------------------------------ W <br /> Number of living units_____________ Number of bedrooms ___________Garbage Grinder ------------ Lot Size ------__________-___-_______.________-____ <br /> 1 <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 ❑ 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,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] Size-----------------------------------•------------ Liquid <br /> Depth --------------------------- <br /> Capacity TYPe� - ____ Material- No. Compartments -�----•------••- <br /> f <br /> _ <br /> 'Distance tol nearest. Well ___________________________________Foundation --- ----------------- Prop. Line ---------------------- <br /> LEACHING <br /> __-_-_- _-__---_--.LEACHING LINE [ ] No. of Lines a- Length- of-each- line---- 55�_____:_____ Total Length ,._I1-�-�__._ _ <br /> :'D' Box ___- Type Filter Material _ _______Depth Filter Material _ ______________________________ � <br /> Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line ________-.______-_---__. <br /> SEEPAGE PIT ['] Depth ------- ___ Diameter ---------------- Ni tuber""_�____.__-____-__________- Rock Filled ;-Yes-;0-�-No-(3 e <br /> Water Table Depth ------------------------------------------------Rock Size -------------------------------- <br /> 1 <br /> Distance to nearest: Well ----------------------------------------Foundation ------------------- Prop. Line --------------------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -.------ ------------------------------------ Date ---------------------------------- <br /> 4 <br /> SepticTank (Specify Requirements) -------------------------------------------------------------------------------------------------------------------------------------•------ <br /> Disposal Field (Specify Requirements) ----------------------------------------------------------- <br /> ---- { <br /> ----------------------------------------------------------------------- ------- <br /> --- _-- - , <br /> xis�ing and <br /> red <br /> hereby certify that I have prepared rth s eappl cation and Ithat ath -_ = J <br /> - - --- - ------- - --- ------------ ------------------- ------------- ----- - <br /> dition on reverse side) <br /> a <br /> e 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 perform ce of the-work faVvA' Ktthis permit is issued, I shall not employ any person in such manner�Ll ` <br /> as to be ject to Wo in's-=sation laws of California." <br /> 5ignedic ---- --- -------- Owner <br /> BY = - ------------------------------ -------------------------- Title ---------- # <br /> --------------- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ---- ----------------- DATE ------- -- _1 u �3------------------ <br /> ------------------------------------------- <br /> BUILDINGPERMIT ISSUED ------ ------------------------------------------------------- ----------------------------------DATE ------- <br /> ADDITIONALCOMMENTS ---------- -t --------------------------------------------- --------- -------------------------------- <br /> - ----------------------------------------------------------------------------------- <br /> -------------------------------------N <br /> ------•-----------------------------•-- ------- --------------------------------------- <br /> -----'-----`------------------------- - ----- 1 <br /> Final Inspection b - - -- <br /> --- - - - ---------------,Date ------- --�� :��----------------- <br /> [ SAN JOAQUIIv LOCAL HEALTH DISTRICT r <br /> r <br /> E. H. 9 1-'b8 Rev. 5M <br />