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FOR OFFICE USE: " <br /> APPLICATION FOR SANITATION PERMIT- <br /> ---------- <br /> % <br /> In Triplicate) Permit No. _7 C.I.. <br /> ......................................................--- This Permit Expires 1 Year ` Date issued <br /> _ From Date Issued 1 <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 Cou y Ordinan No. S49 and existing'Rules and Regulations: <br /> o __ -'_..L�.......... CENSUS TRACT <br /> JOB ADDRESS/LOCATION .. . _. .. �1.�� . ................. .. ............._............ <br /> Owner's Name 16110- ....._ ... one .................................... <br /> Address ... ---- ------------ City .`-!1...... ......... ........................ ...................... <br /> Contractor's Name �. .-.........................License # /..,f ,f. Phone <br /> .. <br /> Installation will serve: Residence partment HouseQ Commercial QTroiler Court ,0 i <br /> Motel Q Other ........... ................................ <br /> Number of living units:......... Number of bedrooms .. .--Garbage Grinder Lot Size ., 5 .. /. ........... <br /> Water Supply: Public System and name -...--___.. ._ ........................... ................................................Private <br /> Character of soil to a depth of 3 feet: $and 0 Silt 0 Clay _ Peat Q Sandy Loam Q Clay Loam Q. <br /> Hardpan Aclobeal ill 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 1f public sewer is available within 200 feet,) ; <br /> PACKAGE TREATMENT [ ] SEPTIC TANK S _. . ... Liquid Depth ...... <br /> --.. <br /> Type Pj..•• .--.- Materlal 17�T1o. Compartments <br /> Capacity/ \ �ti <br /> � <br /> Di be.to nearest: Well ____ __lJ.................. . Foundation X1.1........ Prop. Line . { <br /> ..................... <br /> LEACHING LINE No. of Lines _. Length of ane.__ Total Len h6.�............. { <br /> [ -= . <br /> __ 7f ' <br /> 'D' Box . ..�_'Type Filter Material l� �Vi­bepth__Filter Material- .. .............. ........... <br /> Distant to nearest: Well _-_.6_______..__//__-'. Foundation ---- ............. Property Line . 5.........---...-... <br /> S�-istr Depth ....f............ [Xza weer �_L�.---- Number ............_r), ......... Rock Filled YesNo <br /> / Water Table ......................:...Rock Size --•- . ....... _/ <br /> Distance to nearest: Well ........_ _.j....................Foundation ...f a..�...... Prop. Line 4-_-__............ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# .------------------------------------------- Date } <br /> Septic Tank (Specify Requirements( ............................................. •-•--------------------------•---•--- ..............................--•-..............I........ <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 HeaI1h,0ls1rict. 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 /> Signe --..-- �-•--------- ------ Owner <br /> By - --- - - -....._.. Title <br /> o er than owner) <br /> FOR DEPAR. ENT USE ONLY <br /> APPLICATION ACCEPTED BY .. -------------------- .._.... DATE ..CCS.-, �: .._. <br /> BUILDING PERMIT ISSUED ................ . <br /> ------- --- ---...------ DATE .... = ,.............. <br /> ADDITIONALCOMMENTS ------------- ----------------------------------------- ------•...--------.---------------- <br /> ....._._... <br /> .............. ------ - --•-- -- -- - --- ....-- ----•-- s-----------------.----------_....__.-._._......�. J <br /> ------------ ----------------- ...... ---------- --- -----------• -- ... ---- - ----------------• ..__._.... ... �,,/ �.t, -------. <br /> Final Inspection b <br /> p Y: ..._ _ _ .. ... _ .-----------�:.............. Date .. .......................... <br /> '6 Rev SAN JOAQUIN CAL HEALTH DISTRICT' 8/74 3M <br />