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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> IComplete in Triplicate) Permit No. .__7�,'���3 <br /> ......................................................... This Permit Expires 1 Year From Date issued <br /> Date Issued ...... .:......... <br /> Application is hereby made to the Son Joaquin Local Health District for a per 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 /> JOB ADDRESS/LOC QN ... ..... / n CENSUS TRACT <br /> . . .a <br /> Owner's Name _ ............................................ ------------------Phone .................................... <br /> Address ..,�.Jr' �.. . City ... ..............'.__._........._.._...........••-.......................-- <br /> Contrattor's Name ...-.. `- ---lam^....•--------------------.License # .� .���`. Phone .__.....__..._..__...___-•-... <br /> Installation will serve: Residence P�Apartment House 0 Commercial:[-]Trailer Court i❑ <br /> Motel ❑Other ------------_----------- ............ <br /> Number of living units:........... Number of bedrooms _._..Garbage Grinder ------------ Lot Size ......................... ................. <br /> Water Supply: Public System and name .........................................................----•-•--••----••-•---•-----•• --•-- ------Private ❑ � <br /> Character of soil to a depth of 3 feet: Sand 0 Silt❑ Clay [3Peat[:1Sandy Loam Clay Loam D �} <br /> Hardpan ❑ Adobe ❑ Fill Material ............ If yes,type ............................ �` <br /> (Plot plan, showing size of lot, location ofsystem 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 f ] Size................................................ Liquid Depth ---------------------.---- <br /> Capacity Type -•--•............... Material........_............. No. Compartments <br /> Distance to nearest: Well ...............Foundation Prop. Line .............. <br /> LEACHING LINE [ ] No. of Lines ........................ Length of each line---------------------------- Total Length <br /> 'D' Box ............ Type Filter Material ....................Depth Filter Material .......................................... <br /> Distance to nearest: Well ........................ Foundation ........................ Property Line ........................ <br /> SEEPAGE PIT [ ) Depth Diameter ................ Number -----------................. Rock Filled Yes ❑ No t❑ <br /> Water Table Depth ................................................Rock Size .--............................. <br /> Distance to nearest. Well ..••....................................Foundation -._..-_ Prop. Line <br /> REPAIR/ADDITION(Prev. Sanitation Permit# _....._..._,r............................... Date .................................. <br /> Septic Tank (Specify Requirements) ------------------- ----__ <br /> Di sal Field (Specify Requirements) -- - _ Q�- a.............................. <br /> s !��.. �.. :...... . ... . .�w '' -] <br /> ----------- --------------­ ... ............. <br /> .. __.._... - <br /> t t - <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that 1 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 Compensation laws of California." <br /> Signed ..............................•---- ---- -- --- - - Owner <br /> T <br /> gY ----- ................................ .. '--•1 ` <2___.. Title .... <br /> (If other than owner) t <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ... ....... ... ...... ------------------------. ----.........-•-••....._._........... DATE . ..✓n...7 ......_...... <br /> BUILDINGPERMIT ISSUED ------------------------------------------------------••--•----....._...------.............I.....-----....DATE ......................................... <br /> ADDITIONALCOMMENTS ----------------------------•---...-----------•----------------••---....---...........----•----•-........ <br /> •-•-------------•-••--•------....._.......-•--••••--•----•-------•......---•.........._..._......_..............D....-•-•-•......--------••-- <br /> -• .......- - --.....•._..... <br /> p Y' .Date .1 ..... <br /> Final Ins ection b � .. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H.13 24 1-'68 Rev. 5M 7/72 3 M <br />