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R � <br /> rte. FOR OFFICE USE: <br /> - ., APPLICATION FOR SANITATION PERMIT <br /> ------------------------------------ Permit No: <br /> I (Complete in Trip irate <br /> This Permit Expires 1 Year From Date Issued <br /> Date Issued :/__ ___ <br /> Application is hereby made to the San Joaquin Local,,Hea'Ith District'for,,a permit to construct and install the work herein <br /> described. This application is made in compliance with Coun y Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION .,__.__l ___ ._ ------------. -CENSUS TRACT __________________________ <br /> �� �' <br /> Owner's Namei ---.- <br /> Phone <br /> Address ----- - l.��r'-�----------i-� -. ` City .- --------------------------------------------------- <br /> Contractor's <br /> --------- ------------------ -----------Contractor's Name ----- ' = = License # - } Phone <br /> Installation will serve: Residence ❑Apartment House,M.Commercial :❑Trailer Court ',❑ <br /> Motel ❑Other --- " -/ " ----------- <br /> Number <br /> - --Number of living units: /r. Number'of,bed room s ------------Garbage Grinder Lot Size _. _ Gx� -`} <br /> ] <br /> Water Supply: Public System and namel.- --------- --•-•------•-•- ------------------------------------- ---------------------- Private <br /> Character of soil to a depth of 3 feet: SbndSilt❑ Clay ❑ Peat❑i Sandy Loam -❑ Clay Loam ❑ <br /> i Hardpan ❑, `Adobe 0 Fill Materia! _---- ------ if yes,type ---------------------------- r <br /> (Plot plan, showing size of, lot, locotion,of system in,relation to, wells, buildings, etc. must be placed on reverse <br /> NEW INSTALLATION: {No septic tankfo cseepa pit permitted if public sewer is available within 200 feet,} <br /> > ^ n , _ <br /> � <br /> Liquid Depth ------�+' V <br /> PACKAGE TREATMENT SEPTlCTANK ------------------ <br /> ---------- f <br /> Capacity .111po - � <br /> --- TYp �- + ------ Materia 4_ No. Compartments __. ------------- <br /> i _Well— --------------- ------Foundation -----/0----------- Prop. Line ----d- - ---------D tante to nearest:. - - <br /> LEACHING -J <br /> LINE No: of Lines _.-_-_______________ Length of each line____-_1 -_-_-_---- Total Length _-_9' <br /> 'D' .Box ------- Type Filter Materials .Depth Filter Material ----------J - --------------------------- <br /> O r ---�0.............. Pro ty `� / •------ <br /> Distance to nearest: Well _ -_�7J-_--_-_--.-- Foundationper Line <br /> SEEPAGE PIT [ ] Depth ____.-- -_ <br /> Diameter ________________ Number ____._____________._____=__ Rock Filled Yes ❑ No 0 <br /> Iii t <br /> Water Table Depth Rock Size -------------------------------- <br /> Distonce to nearest: Well ---------------------.__--------- -------Foundation -------------------- Prop. Line ---.____________.___-- <br /> REPAIR/ADDITION(Prev. Sanitation Permit e# -----___----------------------------- ------ ------------- -------------------- <br /> ' Septic Tank {Specify Requirements} ------------------------------------------------------------ ----------------------•----------:----------------,-------------------------•--- <br /> Disposal Field (Specify Requirements) ------------------------------------------,-----------------4 <br /> -------------------------------------------------------------------------- <br /> i ------- <br /> -_-_ ----_-----_____--_-_--_-_---_-__-_----_---__------_--------_ <br /> _____________________________________________ ----------------" ----------- <br /> 11 (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 /> F 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 whiih tliis�perm ifYis issued, 1 shall not employ any person in such manner <br /> as to beco a subject o Work n Compensation'laws;of California." z <br /> Signed ------------- - -: ----- ----------- -------------------- =�". - s dwn•� eerr - <br /> s='Titl <br /> (If other th er] e ---------------- <br /> Y - <br /> n own <br /> I <br /> I OR EP RT N USE ONLY <br /> APPLICATION ACCEPTED BY ------ -------- - ----- --------------------- <br /> ------------- DATE ---- <br /> BUILDINGPERMIT ISSUED -1-----=----------------------------------------------------------------------------------- --------------DATE ------------------------------------------ <br /> ADDITIONALCOMMENTS ' -------------------------------------------------------------------------------------------------''-------------------------------------------------- <br /> ----------------- ---- - <br /> ---------------------------------------------------------------------------- t <br /> ------ ---- ----------------- ---------------- <br /> 11 -------•--------------------•---- <br /> ---------------- <br /> ------------------------------ ------ -------__---------------.::-.,-.---_---- ----- _ -: ----------------------- <br /> --------------- <br /> ._.:_--- ---------- <br /> 1 <br /> Final Inspection b -_ Date __ - ------- --------------- <br /> p Y -------------- - ------- <br /> ------- - - - <br /> I SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68-Rev. 5M <br />