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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT _ <br /> ----------------------------------- Permit No.CI�f�.� _.. <br /> (Complete in Triplicate) <br /> __________________________________________ ______________ This Permit Expires 1 Year From Date Issued A <br /> Date Issued'____.__::r_ _ . <br /> Application is hereby made to the San Joaquin Local Health District for a per to construct,:and~instal l the work herein <br /> described. This application is made in compliance with County Ordinance No. 549 and existing-Rules and Regulations: <br /> JOB ADDRESSAOCATION /- ,S�C7 `_ - ENSUS TRACT __________________________ <br /> Owner's Name ------------------ /-- ------ -- Phone _-L77.—_>-�o-.�1_ <br /> Address -------------------------- 1 -- ------- � __. City ---- -- ------- -------- <br /> -- - -- - - ------ -- -- - - -- ------- ----// <br /> Contractor's Name ----------------- ----- --- -- - - ` --- -_ - ------.License #1ZD.SL1------ Phone '766-"x_ d_t . - <br /> Installation will serve: Residence Apartment Hous"e�❑-Comirriercial'{]Trailer Court 0 <br /> Motel ❑Other-------------------------------------------- <br /> r <br /> Number of living units:---- Number of bedrooms ___,5-----Garb6g' e,Grinder __________ Lot Size __ ___________________ <br /> Water Supply: Public System and name f�_--_ _________________________________________________________________________Private <br /> f <br /> Character of soil to a depth of 3 feet: .Sand'❑ Silt❑ . Clay .❑ Peat,❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe k Fill Material ------------ If yes, type -----------_-------_________ <br /> (Plot plan, showing size of lot, location of system iA 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 Depth <br /> ------ <br /> , -- <br /> ------------------------ <br /> ap Y ----- Type Material_T______ :_____ No. Compartments , ------------------•--- <br /> Dtana to nearest: Well __.___._. ------------- <br /> ------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 /> i _____________Rock Filled Yes C] <br /> SEEPAGE PIT [ ] Depth ___------_____------ Diameter ________________ Number .___________._ * ❑ No <br /> Water Table Depth ------------------------ ------Rock Size ------- ------------------------ <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ---------------------- <br /> it <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -----------------------_ ___________.________-_- Date __-_-_._-___-_____________________) <br /> Septic Tank (Specify Requirements)' ---------s --------- ---------- ------- *---------- ---------- ---------------- <br /> ----------- <br /> Disposal Field (Specify Requirements) ------ <br /> ,_____ ___ ------ _ ----------�------- _ <br /> -------- `?�/�' � r <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, andRules 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 -------------------------- - r Owner <br /> --------------------------- <br /> BY ---------- ----------------------- Title ------ -------- <br /> (If other tha ner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -6--- ---- -- ------------------------------------------------------------ -- ------- DATE ----------- <br /> BUILDINGPERMIT"ISSUED ---------------------- -----------------------------M ---------------------------------------------------DATE ------------------------------------------- <br /> ADDITIONAL COMMENTS --------------------------- <br /> 4 <br /> __ _____________________________ti____________----_--_____________________--_--_____.._________.___________________________-________________._____._______ <br /> ___--________________________________________�___.,� _____------____-_-_____s__=__.__-------------____k__.____-_.C__%______________._-___-__-__________-__-_--__----____-_-__-____-_____.____..____ <br /> __________________________________ _ __ ___ _ ___ _ <br /> Final Inspection by: ___-r. - -, <br /> ----- <br /> --------------------- -�-------------------- ------------------ - -- - -------Date f-Z- j-�- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />