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FOR OFFICE USE: � 0 13 ,110 <br /> APPLICATION FOR SANITATION PERMIT <br /> `-crb Permit No. <br /> }� (Complete in Triplicate) <br /> - ------------------------------ <br /> ----------------------------------- This Permit Expires 1 Year From Date Issued Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a permit to cotistruct and install the work herein <br /> described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> { { <br /> JOB ADDRESS/LOCATION'!---6- ------------ ---- - - --- CENSUS TRACT <br /> Owner's N Phone <br /> -- ----- - - <br /> .. ` ' _8/_fes!- -----. Cit <br /> Addre R " T Y ---------------------------------------- <br /> .,�� p p- - <br /> Contractor's Name ..- --J^ Y-.- - -- --- -- +fes'- --�2 --- __-- - License #1c�l� J�l'tl_ Phone --------------- -------------- <br /> Contractor's <br /> will serve: Residence Apartment House❑ Commercial ❑Trailer Court ;❑ <br /> Motel ❑ Other ---------------- ----------------------- <br /> Number of living units:---- Number bedro ms�--___ rbag Gri er ------------ Lot Size _ © -- - - ---.---- <br /> 1 Private <br /> Water Supply: Public System and name _ ______ _ ±J__ �-- ¢e�uu` - -----------• ❑ <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ <br /> Vq <br /> Hardpan ❑ Adobe [:f Fill Material ----------- 1f yes, type -------------------------_. <br /> f, x <br /> (Plot plan, showing size of lot, location of sem- tem in relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seep a pit pe mitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK'[,] Size----------------------------------------- -- Liquid Depth _____---.---------------- <br /> Capacity --------------------- Type --------- ------ Material---------------------- No. Compartments -----------•-• ------- <br /> t Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ----------- ---------- <br /> LEACHING LINE [ j No. of Lines ----------------------- Length of each line--..------------------------ Total Length ----------------- ---------- <br /> .'D' Box -------- Type Filter Material --------------------Depth Filter Material --------------------------------------•----- <br /> Distance to nearest: Well ------------------------ Foundation -------------- --------- Property Line __________.____--...-- <br /> iSEEPAGE PIT [ ] Depth -------------------- Diameter ----------------- Number -,---------- - -------------- Rock Filled Yes ❑ No i❑ <br /> Water Table Depth ------------------------------------------------Rock Size ------ ----------------------- <br /> Distance to nearest: Well .______----_-___ _._____Foundation ____________ Prop. Line ________________ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------- -- Date ----------------`--- -.----------} <br /> Septic Tank (Specify Requirements) <br /> Di osal Field (Specify Re uirements) ---. _ . ______________ - <br /> su. R�---- --------- --�.�— - - �- <br /> _ - <br /> k..�.. .� ` ------------------ --- -------------------------- <br /> raw existing and re ired addit' n on reverse side) <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: <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 becpr�7 }b ct to W rk`an' Co s of California." <br /> Sign v__��---J- -t i__ ------- --------�. <br /> le ------------ ------------------------------------------- <br /> (If other than owner) <br /> FOR DEPART ENT USE ONLY <br /> APPLICATION ACCEPTED BY -- DATE --- . ---- -- ----------------•- <br /> BUILDING PERMIT ISSUED .--- --DATE ----------------------------------- ------- r <br /> ADDITION5SCOhAMENTS ------- ------ - - <br /> ---------------------------------- <br /> []� = <br /> Final Inspection by: . Date <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M7/ <br />