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-FOR OFFICE USk:4 APPLICATION FOR SANITATION PERMIT � pppp <br /> -------------------------------------------------------- Permit No. _ 04/ <br /> (Complete in Triplicate) ��� <br /> Date Issued _.__-_____ __•._-. <br /> This Permit Expires 1 Year From Date Issyed <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-WithlCounty Ordinance'No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION -- ` f, -. -�. �--------- TRBE.jl �-:. CENSUS TRACT ---------- -�------ <br /> :.L <br /> Owner's Name -------- ----------------- ----------- -------------------Phone <br /> Address ------ 0-13_%-__-----�.--- 4a1V—E -6�--------------__. City -----Esn—s7;S/---------------------------------•-••--- <br /> Contractor's Name ....... -------- ----------------------------------- License # ---------.-------------- Phone ------------------------------ <br /> f <br /> Installation will serve: Residence WrApartment House❑ Commercial []Trailer Court ',C] <br /> tel <br /> Number of living units:_._(.! ----INu�ilaeroof �drooms _______Garbage Grinder ._ 1-_ Lot Size __ 1 —--------•-_ <br /> Water Supply: Public System and name ----------------------------- --- --------------------------------- -------------------------------- ---------Private [ � <br /> Character of soil to a depth of 3 feet: Sand'❑ Si !❑ Clay ❑ Peat kill, 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.) . J <br /> NEW INSTALLATION: (No septic tank or'see ige pit permitted if public sewer is vailable within 200 feet,l <br /> PACKAGE TREATMENT [ ] SEPTIC TANK[.]- -..--Size__-_-_:------- '----.------ •------------ Liquid Depth U} <br /> Capacity - ------------------ ype -------------------- Material------------- --- ---- No. Compartments <br /> Distance to nearest: ell ------------------------------------ ----- ---- Prop. Line ---.-------•---------- <br /> - - -- ----- - <br /> LEACH&G•LINE [ ] No. of Lines _______________ ______ Length of each line---- ____-�.-{'_ ---------- <br /> Tota[ Length ___---_____.-__------------ <br /> " - D' Box ------------ Type Iter Material _-_--------.___Depth" Fi.lt rMaterial --------------------•------------------. <br /> I <br /> Distance to nearest: W 11 -----°------------------. Foundation _._______ _R.____-_-___ Property Line _________-__-___-_.__. <br /> SEEPAGE PIT [ ] Depth ---------�-------- Di meter --------- ------ Number ---------°--- -------------- Rock Filled ,Yes ❑ No �❑ <br /> Water:Table jDepth ---- ----=------ ----- ---Rock Size ..,_--_- _ - - A`x 1 <br /> i <br /> .;Dista ce,to,neare'st: e -------FoundaTi Prop; line.----------- <br /> W _. <br /> REPAIR/ADDIIION(Prev. Sanitation'Permit# ----- .------•----------------------------- Date -----_-- ----- --•---------------} <br /> : .---_._ <br /> Septic Tank (Specify Requirements): ---------------------------------------------------------- ...-----..__�_�,_ <br /> -------- <br /> Disposal Feld (Specify Requirements) _ �_-7`�_. K•--"_---- <br /> ----------- <br /> ----------- --------- � ��f ` 1 _ p r- ' •• - <br /> t -------- -- `- - '--------------------------------- --------------------------------�---------- <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 S6L Joaquin Local Health District. Home owner or licen- <br /> sed agents signature certifies the following: i } <br /> "I certify t in t e perf, rm nce of the work for which this permit is issued, I shall not employ any person in such manner <br /> as to b es ect to man's Compensation laws of California." <br /> Signe --------- -- ------ 11. -------s----------a---------- Owner <br /> By ---- ------------------- ------------------------------ � F* L'------- Title ------------------------ ---------------------------------------- ------ <br /> (If other than owner) <br /> TTa� FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ------�{ I�--0-------------`--------------- -----------------•.----- ----------• DATE <br /> BUILDING' PERMIT-ISSUED ------- - _ ., . - — - - - ----------------- - - <br /> - ------------------ - ------------------------------------------ - -- - -- - <br /> ------------------ <br /> ADDITIONAL COMMENTS - =` ='ir d vz �,��- - ----------------------------------- ------- <br /> ------------------------ <br /> - - --------------------------------------------------------------------------- -__------ <br /> -•--------•- --------------------- - - ----- -------- - ------ -- --- - --- -- - __ . <br /> ------------ <br /> ------ - - ---- - - - - <br /> Final fnspe Date <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />