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.� , FOR OFFICE USE: - � <br /> APPLICATION FOR SANITATION PERMIT <br /> ...................----------••------. - ........... Permit No. .2 <br /> (Complete in Triplicate) <br /> ...............I........................ This Permit Vxplres 1 Year From Doh Issued <br /> Hate Issued ..5.."�?......7. <br /> Application is hereby made to the San Joaquin Local Health 'bistrict for a permit to construct and install the work herein <br /> described. This application is made in complian a wit linty Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOC ON ..- _.. . ._. ._ 1®�f.±!............................CENSUS TRA <br /> Owner's Nam .. ....................Phonf....~ ��._. <br /> .. e <br /> ty <br /> Address ... . .........: Ci <br /> Contractor's Name ................................... ...................................................License ........................ Phone .............. ............... <br /> Installation will serve: Residence @ Apartment House Commercial OTrailer Court 0 <br /> Motel ❑Other .......----•.... ........................... , <br /> Number of living units:.__...__ Number of bedrooms ........Garbage Grinder ............ Lot Size ......... .- .........•........-- �J <br /> Water Supply: Public System and name .......--.Pt1! ............................ ..Private <br /> Character of soil to a depth of 3 feet: Sand'® Silt[3 Clay [] Peat Q Sandy Loam j] Clay Loam j] <br /> Hardpan j] Adobe 0 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: , <br /> (No septic to or seepage pit ,permittedFif pu 5 sewer is available within 204 feet,) <br /> : <br /> PACKAGE TREATMENT j SEPTIC TANK j } Size------------=- i_.__..............:... Liquid ..Depth _....��[. ...... <br /> --Via _... Type ._ !!!j"! �_.Material... !? ...... No. Compartments ....2. <br /> t Distance-to nearest: Well _._ .................... .. .......... Prop. Line __��..... <br /> LEACHING LINE [ ) No. of Lines 5---------:___ length of each line--------.70.0 . ...... Total Length .--Z <br /> .> ......... <br /> ..__. <br /> 'D' Box .. Type Filter Material ....................Depth .Filter Material ............................................ <br /> Distance to nearest: Well ....._.............:... Foundation ................ Property Line ........................ <br /> SEEPAGE PIT ( ) Depth --=----------- ----- Diameter ............... Number -----..-_---_-------_------ Rock Filled Yes }] No <br /> Water Table Depth -----------------------------';-------------------Rock Size ................................ <br /> r <br /> Distance to nearest: Well .:Foundation Prop. line <br /> REPAIR/ADDITION(Prev. Sanitation Permit# .......................:.................... Date°---------------------.------.-----I <br /> Septic Tank (Specify Requirements) <br /> Disposal Field (Specify Requirements) ------------•--- --- ----•-•-----• -- -•-------•-----------•-•--•••••---...---•.........-•---•..._. <br /> ----------------- ------------------------------------------------------------------------------•----- -------------------------------------------------------- ................... <br /> -----------------------------: - ---------------•---•-----••------------ ...............-......... ..................... <br /> (Draw existing and required addition on reverse side) x <br /> I hereby certify that ! have prepared this application and that the work will :be clone 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 ' e performance of the work for which this permit is'issued, ! shall not employ any person in such manner <br /> as to beco 'ec P o Work a Mn ws of California." <br /> I <br /> Signed +" <. ..__..._ �, -• ----- Owner <br /> B -------------------------------------------- .�. ------ ---------•-------•-- Title _.-------- -----_----•-------------- ................. --• <br /> (if other than owner) <br /> DEPARTME USE ONLY <br /> APPLICATION ACCEPTED BY ---------------- DATE ........ .... ......'. . <br /> - - -- -- ------------ <br /> BUILDING PERMIT ISSUED _-------------------- _DATE -.------....-_-_-_.. . <br /> ADDITIONAL. COMMENTS ----..-------------------------------------------------- --------•:................................... -------_ -----.------..._...-----------------• -•-- <br /> ------ •------------• - ------- • .................... -- .----------------------------•---•---....---•---------------.. .1,...... ............ <br /> ----------------------- --------- . ....-.....-------... . ....--•---..................._............. ------------- --------- y- �.j1- ----..-•------- <br /> �.Finai Inspection b ----Date ............................................ <br /> EH 13 2a 1-68 Rev. 5M SAN JOAQUIN LOCAL HEALTH DISTRICT 8/711 3M <br />