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ci <br /> FQR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> -- ----- - ------- Permit No. .�_�Y�' 7 <br /> (Complete in Triplicate) <br /> --------- <br /> This Permit Expires 1 Year From Date Issued Date IssuedZ1 <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 w th County Ordina ce No. 549 and existing I�ujps and Regulations: <br /> JOB ADDRESS/LOCATION . f �� 5-------- w--`......5---0-------------------------------CENSUS TRACT --------------- - <br /> Owner's Name / l'3 � .'�`-------45�r----- 2i►'?'----•----------------------------=-•-------------------Phone --------- <br /> Address ..../.:2-5-76-��-------1 _ v_670 --. Cit A*,Ax Ir' <br /> Contractor's Name -- fl=---- ---_ - -�_�,q1/`e------------------•-:--------License I_.3�` _ Phone _ �� "'-------- 7 <br /> Installation will serve: Residence ❑Apartment House,(fj Commercial : Trailer Court ;❑ <br /> Motel ❑Other -------------------------------------------- <br /> Number of living units:----------- Number of bedrooms ------------Garbage Grinder ------------ Lot Size 1f - <br /> Water Supply: Public System and name ---------------------------------- --------------------------•---------•---------------------------- ---------Private <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt o Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam <br /> Hardpan ❑ _ Adobe;Q f4,Fill.Material ------------ If yes, type ---------------------------- <br /> (Plot <br /> --------------------------(Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) s <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) o <br /> PACKAGE TREATMENT' [ ] SEPTIC TANK'[ ] --- -------- Liquid Depth —_-___,_____ 1 <br /> Capacity 12­0��------ Type Ma#erialNo. Compartments __________________ <br /> Distance to nearest: Well ______ ------------------ -------Foundation ___r_ ___ ___ Prop. Line __'-------- ...... N j <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 ---------7_6________ Foundation --115?___ _________ Property Line_ ___0____.--------•...... <br /> SEEPAGE PIT [ ] Depth ____________________ Diameter _: ____________ Number ---------------------------- Rock Filled Yes ❑ No [3q <br /> Water Table Depth ------------------- ----------------------------Rock Size ------------------------------ <br /> Distance <br /> ----------------------------Distance to nearest: Well ________________________________________Foundation --------------_----- Prop. Line ........__........__.. ! I <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------I . <br /> SepticTank (Specify Requirements) ----------------------------------------------------------------------------------- ---------------------•-- ----------------------------- <br /> DisposalField (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 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 /> BY -------- --- ! C�f Title --- <br /> I - - <br /> (If other than owner) 1 <br /> ` FOR .DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ________.__ 16-1711 <br /> ------------- -------------------------------------------------- ------ DATE ------- -------------- <br /> BUILDING .PERMIT ISSUED ----------------------- <br /> - ------- -- -------- ----------------------------------------- ---- ------------=--------------DATE ------------------------------------------- , <br /> ADDITIONALCOMMENTS -- --------------------------------------------------------------------------------------------------------- <br /> { <br /> --------------------------------- ----------- ------------------------------------ <br /> - ---------------------------------------------------------- ------------------- ------- ----- <br /> Final Inspection by: ------- -- --------- --- ------- ---- ` --------------------------- --- -------------Date -----�- j <br /> ------------ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT j <br /> E. H. 9 1-'68 Rev. 5M { <br /> F <br />