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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT . <br /> ------------- ----------- Permit - <br /> 't N a: <br /> ?� {Complete in Triplicate) <br /> - <br /> ----------- <br /> - 7a <br /> - <br /> ------------------------------ ----- This Permit Expires 1 Year From Date Issued <br /> Date Issued <br /> _. l ? 3.— 270 --l/ <br /> Application is hereby made to the San Joaquin Local Health District fora permit toy construct and install the work herein <br /> described. This application is.made in compliance wit County Ordinance No. 549 and existing Rules and'Regulations: <br /> JOB ADDRESS/LOCATION ��5i._ .t:.__Q"FJM KiJ1-Icy-- .tL!__�_ Gtt.` 1 - Qm� ------- --CENSUS TRACT - ---------- t <br /> Owner's Name ���a --------II--- -------------------------------------=-I------------- <br /> Phone --8G <br /> s <br /> Address <br /> -. ''` --------=------------- --stir----------------------. City f►°P..+c �------------------------------------------------ <br /> Contractor's Na a <br /> - --_. <br /> --- ----------�- .•�s�-��r�✓�ts._✓_�--f_st,�_d�_Cl License # ------------------------ Phone - ---------------------- <br /> Installation will serve: Residence E-]Apartment�House-❑ Commercial ❑Trailer Court l❑ <br /> Motel ether _Mold e-tTa.ww--t------------- <br /> t <br /> Y <br /> Motel <br /> ] <br /> Number of living units------------- Number of bedrooms _I________Garbage Grinder ------------ Lot Size ___1 --------------------------- <br /> Water <br /> ---- ______.____.____-._ <br /> Water Supply: Public System and.'name ---------------Well-----------.---------------------------------------------------------------------Private (� <br /> Character of soil to a depth of 3 feet:R Sand'El Silt fl -Clay ❑ Peat❑ Sandy Loam Clay Loam 0 ^.fl <br /> Hardpan ❑ Adobe-❑ Fill Material ------------ If yes, type ________________________ <br /> (Plot plan, showing size of lot, location of system -in relation to wells, buildings; etc. must be placed on reverse side.) <br /> NEW INSTALLATION: t (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) I! <br /> PACKAGE TREATMENT f ] *SEPTIC TANK Sizex_6r � (a _ !---------- Liquid Depth --v4r------------------- <br /> s} <br /> I Capacity800_�._ __Type RWC------- Material_ =!'tll h'T:_. No. Compartments ---ems_-------------- n <br /> . D' tance'to nearest: Well '{ De----------------Foundation �o�t_____________ Prop. Line -XJO-e <br /> LEACHING LINE [ No:. of Lines -7----------------- Length of each line___ ,0__11_______._____ Total Length -,rZ&............ <br /> 'D' Box Type Filter Material Rot------_Depth Filter Material _ ---------------------- <br /> Distance <br /> ___________________Distance to nearest: Well --- ------------ Foundation ---- /a*-#----------- Property Line -J0­­­-- <br /> SEEPAGE <br /> _Q__.._.__.__SEEPAGE PIT [ ] Depth.____---F_ a____- Diameter------------ Number. . = Rock-Filled Yes 0 No <br /> Water Table Depth ------------------------------------------------Rock Size _:_._-.---------- <br /> "" Distance to nearest: Well _____________________ --------------Foundation --------- - - - Prop. Line ---------------------- <br /> REPAIR/ADDITION{Prey. Sanitation Permit# ------------------------------------ ------ Date _______________-_______________) <br /> Septic Tank (Specify Requirements) -------- ---------------------------------- ---------------------------------------- ------ <br /> DisposalField, (Specify Requirements) ----------------- ------------------------------------------------------------------------------------------------------------------- <br /> -------------------------------------------- -------------- ----------------------------------------- ------------------------------- ---------------------------- � <br /> - -------- ---- -- - - -- --- <br /> -- - -- ---------------=-------------------------- -------------------------------------------------------- <br /> {Draw existin g and required addition on reverse side) <br /> I hereby certify that 1 have prepared this application and that the work ill be done in accordance with San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaq 'n 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 --- "°L -------------------------- Title Title I <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY _.,qg�7s,-t_41 --- ------------------------------------------ ---- DATE ---"�1^l Ll.-~--�lL-.----------- <br /> ----------------- - <br /> BUILDING PERMIT ISSUED --- ------------------------------------------------ -------DATE ----------------------------------------- <br /> -----------------------=---- - <br /> ADDITIONAL COMMENTS ------ s --....----------------------------------------- <br /> ----------------------------------------- -- -- -- <br /> --- -------- <br /> ---- <br /> - <br /> - Date -�1dFinal Inspection by --------------- ------------- -- --------------- ---------------- --- -------- <br /> - ---------- -- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'b8 Rev. 5M. <br />