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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> Permit No. _ �--- <br /> . ----- <br /> r� (Complete in Triplicate) <br /> ----- Date Issued <br /> This Permit Expires 1 Year From Date issued <br /> ------------------- <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 with County Ordinance No. 549�d existing <br /> nd f g Rules <br /> and Regulations: <br /> -------------------------- <br /> --- <br /> D�^�_t �_ _ ---- ------ CENSUS TRACT <br /> JOB ADDRESS/LOCATION - //`�1�__-- -rs� -- (� ' <br /> r yp fe�d+��ll�-��'°M" ------Phone ------------------------------------ <br /> ---- <br /> ------------------------ <br /> Owner's Name r!- e.- / E-1[e- f---F-S�'� --€�-------- - y <br /> ------- ------- --- <br /> d ---------- city ------------------ - -- <br /> , <br /> Address ------------------ + �-�_ fly <br /> - ----------- <br /> /QfJ�/1 _ Phone -------------------------- <br /> Contractor's <br /> --- ---------------------Contractor's Name -------------------------------------------- <br /> —-- ------- - - - - -------- --------License # ---- �--.---- ------- <br /> i <br /> Installation will serve: .'Residence Apartment House❑ Commercial ❑Trailer Court ',E] <br /> Motel ❑Other -------------------------------------------- <br /> i Number of loving units:__________ Number of bedrooms --�-_--__Garbage Grinder _---.------- Lot Size ----- 4�'- -� <br /> I Private <br /> - <br /> Water Supply: Public System an Home ---------------------------------- -- - - - ---- - - "---- Clay Loam :❑ <br /> � Character of soil to a depth of 3 feet: Sand'❑ Silt fl Clay ❑ <br /> Peat [:] Sandy Loam ❑ Y <br /> y e ---------------------------- <br /> Hardpan ❑ Adobe [] Fill Materia! _____.______ I es,type -S) <br /> (Plot plan, showing size of lot, location of system°in relation to wells, buildings, etc. must be placed on reverse side.) c3 <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,] <br /> i <br /> Liquid Depth __ ------- + <br /> PACKAGE TREATMENT [ ) SEPTIC TANK)< Size-_a -�-a q p ! <br /> yp _ Materia ---- -- NoCompartments -----.......... <br /> ----- • -2 <br /> Capacity .1-8-120-------- T ]4-- _-_ l Type]444,1_1 <br /> � , <br /> Distance to nearest: Well ----------_;�Z----------------- <br /> Foundation _.-------------------- Prop. Line ------ <br /> Len th of each line I_00 � ' <br /> LEACHING LINE � No. of Lines�--------- - g <br /> f��_---_ __ -- Total Length -Q .,..•-•-- <br /> P"'a- De th Filter Material _ <br /> 'D' Box --I----- -- Type Filter Material ---------------�- p o <br /> __ Foundation _--_ - 1--------- Property Line ----�4--------•--- �1 <br /> Distance to nearest: Well _-��----------- 'la <br /> Depth ------- Diameter ---------------- Number -- -------------- ------ Rock Filled Yes ❑ No 0h <br /> SEEPAGE PIT [ ] p -- -�=---- - <br /> Water Table Depth --------------------------------------------I---Rock <br /> ---------- -----------•---Rock Size -------------------------------- <br /> Distance <br /> ----------------------- ------Distance to nearest: Well ------------------------------------------ -------------- ---- Prop. Line ---------------•----- <br /> � - ----------------- -- Date --------------------- <br /> ----------- ) <br /> REPAIR/ADDITION(Prev. Sanitation Permit# --------------- <br /> ----- <br /> Septic Tank [Specify Requirements] _ ----------- ------------------------------------------------------------•-------------- ' <br /> Disposal Fiel (Specify Requirements) -_? - <br /> --------------------------------- <br /> ----------------------- <br /> ----- --- -- - -- -------------- ---------------------------------------- <br /> (Draw existing and required addition on reverse si e _ <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: person in such manner <br /> "I certify th t in the performance of the work for which this permit is issued, I shall not employany <br /> as to bec me ubject to Wor an's Com ns tion laws of California." <br /> Signe --- <br /> 4 -------- - - --- - ---------- <br /> Signe <br /> Title -_ <br /> By __ <br /> [[[ <br /> (If other than owner] <br /> FOR DEPARTMENT USE ONLY f <br /> DATE -/-d---���.~-Z�.----------- <br /> APPLICATION <br /> -- -------APPLICATION ACCEPTED BY _--��-------- --- --- ------ <br /> BUILDING PERMIT ISSUED -------- -------------- ------------------ --------------DATE <br /> ' ADDITIONAL COMMENTS ---------------------------- ----- - ------------------- ------------------------------ ------------------------------ <br /> --------------------- <br /> -------------- ------------------ ---------------------- ---------- <br /> A--------------------- ------------------------------- --------------------------- <br /> ------- - -- - r <br /> Date -- ------------- <br /> Final <br /> ---- - <br /> Final Inspection - -- --- - ------ ---=----- ----- ----�---- <br /> SAN J AQUIN LOCAL HEALTH DISTRICT <br /> k E. H. 9 1-'68 Rev. 5M . ' <br />