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FOR OFFICE ,USE: APPLICATION FOR SANITATION PERMIT Permit No: . .�j-/ <br /> --------=------------------------------------ ------- <br /> (Complete in Triplicate) <br /> ---------=------------------------------------------ q <br /> Date Issued _- �------.1�/ <br /> ---- This Permit Expires 1 Year From bate Issued <br /> Application is hereby made to the San Joaquin Local Health District for a per toAconstruct and install the work herein <br /> described. This application is made in compliance with County <br /> Ordinance No. 5494'and existing Rules and Regulations <br /> JOB ADDRESS/LOCATION / Go®-- -�/- ---------------------CENSUS TRACT __-Y. __YT <br /> Owner's Name ------ --- ---------------- t Phone <br /> Address ------------- �' _ . City61 ,_4; =------------ --------------- <br /> Contractor's Name --------- ' --- --.License # 4 :3 Phone ------------ ---------------- <br /> Installation will serve: Residence Apartment'House-❑ Commercial :❑Trailer Court i❑ <br /> ti <br /> Motel ❑ Other ----- ------- <br /> Number of living units:-_._---- Number of bedrooms_ ______Garbage Grinder�___._ Lot Size ---------------------------- <br /> Water <br /> ___ _____________ _______Water Supply: Public System and name ------------------- ---------------------------------- Private <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt 1] Clay ❑ Peat 0 Sandy Loam Clay Loam;❑ <br /> Hardpan ❑ Adobe❑ Fill Material------------ If yes, type ---------------------------- <br /> (Plot <br /> _______._____ ------ ---(Plot plan, showing size of lot, location of system—in-relatioriat'o-well-s-buildings; etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or see eg <br /> e pit permitted if public sewer is available within 200 feet,] ` \ <br /> PACKAGE TREATMENT [ ] SEPTIC TANK'[ -�..�-_._Size lid-_ - :.�`.v ---- Liquid Depth _�------------------- <br /> j)��-_ _ T ' Material- --?-- --� No. Compartments � -------- <br /> t: <br /> -- --`.::-- <br /> Capacity -' --- -t Type �'' r``��-: - <br /> Distance to Weare t: iWel "rO__________________Foundation,>.-:[P_--___.______ Prop. Line ._____ ..__:�_____ 0 <br /> LEACHING LINE [ No. of Lines-�--.--,_.___r____ 1Lengfih of each line_--_--_��--�--.------ Total Length ___�_ ......... � <br /> _%,i-.---� } , r_ <br /> ____De th Filter Material _---__-_j.�__ ._ `f <br /> 'D' Box __-- Type Filier Material_=." r�' p -- --------••--=---•--•- �T <br /> Distance t nearest: Well`----------Sb_rFoundation_""`-i_-__�_0-�---- Property Line i`__` ------------- <br /> SEEPAGE <br /> ________________ <br /> SEEPAGEtPIT [ ] Depth -------------------- Diameter ................. Numl;er --------- ------------------ Rock Filled Yes ❑ No <br /> ti <br /> R� Water Table Depth i------------Rock Size ------------------- <br /> i <br /> . ._ _.--- ---- Pro <br /> Distance to nearest: Well 1----------------------------•----------- <br /> Foundation ---------------- p. Line ------•-.---------_-•- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ------ ------------------------------------ Date -----'----------------------------1 <br /> Septic Tank (Specify Requirements) ---------------- '--------------------------''-L- °4-f-----------------­-------- ------------- ---..-------------------------- <br /> 11 <br /> Disposal Field (Specify Requirements) ------------ ---------------------------------------------------=-------------------------------------------------------------------- <br /> --------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------- <br /> r <br /> -------------=------------------------------ :-------------------------- -.-- --------------------------------------------------------- -------------------------------------------------- <br /> (Draw existing and required addition on reverse side) -- 7, .� -M <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 /> I 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_ s ct to Workman's Compensation laws of California." <br /> Signed - - -- --- -- --- ------------- ----- ------------- ------- <br /> -- ---- Title Owner <br /> - -- --------------------------------- <br /> 7 <br /> (If other than owner) <br /> FOR .DEPART,, ENT USE ONLY <br /> APPLICATION ACCEPTED BY -- - -- ------- -------------------------------- DATE9'1- _T-- --- --------------- <br /> BUILDINGPERMIT ISSUED -------------------------------------------------- ---------------- ----------------------------------_-DATE ------------------------ <br /> ADDITIONALCOMMENTS ------ ------------------------------------------- -------------------------------------------------------------------------5---- --------------------------- <br /> ------------------------- ------ ----------------- ---- ----------------- ------------------------------------- <br /> ------------------ ----------------------------------------- --------------- <br /> -------------- <br /> Final Inspection by. = -------- -------------------------------------------------------.Date --.~or- ----- ----------------- <br /> SAN <br /> - <br /> SAN -JOAQUIN LOCAL HEALTH DISTRICT <br /> I� E. H. 9 1-'68 Rev. 5M. O� <br />