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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> ------------- ------------------ (Complete in Triplicate) Permit No. ?0--o�oa2 <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 construct and install the work herein <br /> described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> { JOB ADDRESS/LOCATION . --•---'�Y------�!_r,�re-.-_/�-.�� <br /> CENSUS TRACT -------------------------- <br /> i Owner's Name -----C� '- - 7 r ....-. <br /> Phone. � •- / c------- <br /> Address ---------------/� --- --------- /�`-( l X ----. City _:- Y/! ----- -------------------------------------------- <br /> ----------Contractor's Name -----Z�=._AV_T A_C;ZCx--_---f-- �v/!l---___-______-__--.License # _- -- Phone _ - _%�'`-- <br /> t <br /> Installation will serve: 'Residence ® Apartment House❑ Commercial:❑Trailer Court l❑ <br /> Motel 0 Other --------------------------------------------- <br /> F, <br /> Number of living units:---- Number of bedrooms -------- Grinder -fyo----- Lot Size ---- <br /> Water Supply: Public System and;name ------------- ----------------------------- - ------------------•--•--•---------------------- --------Private <br /> Character of soil to a depth of 3 feet: Sand'[] Silt❑ Ciay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ <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: (No septi tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK'{ ] Size---------- --------------------------------.-- Liquid Depth ----------------:._-_----- <br /> Capacity -------------------- Type -------------------- Material---------- --- ------- No. Compartments ---•-----•-•- ----•••• . <br /> IDistance to nearest. Well ------------------------------------Foundation ---------------------- Prop. Line ----------•----------- <br /> LEACHING LINE { ] No. of Lines ------ ---------- Length of each line---------------------------- Total Length ---------------------------- . <br /> 'D' Box ------------ Type Filter Material -------------------'Depth Filter Material --------------------------------­------------ <br /> Distance <br /> --___--._ --..---_.-Distance to nearest: Well ------------------------ Foundation --.-._______--__-------- Property Lirie--------:- <br /> SEEPAGE PIT ( ] Depth -------------------- Dia-meter ---------------- - Rock Filled Yes <br /> Number ------ ---- ------------ -- ❑ No .i❑ <br /> WaterTable Depth ------------------------------------------------Rock Size ----------------------------------- <br /> Distance <br /> - - ----- <br /> Distance to nearest: Well ----------------------------------------Foundation--------------- ---- Prop. Line ---------___------ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ------:------------------------------------- Date ---_----._---__-__-_--__--_-_-_-_) <br /> ay <br /> SepticTank (Specify Requirements) -----------=----•---------- --------------•- -------------------------------------------------------------- _--------------------------- <br /> ` Disposal Field (Specify Requirements) -----_-/ f:f - .------ `l�-1'1'" j}`/��. - --------------------------r, L- -- /--I <br /> .... . <br /> - <br /> � - "` ' <br /> ........... ------------------------------------ i - - - ---- ---- --=--------- <br /> ------------------------ <br /> ------------------------ --------------:+----- =•-•--------- -----------------------------------•------------- ------ --------------------------------------------------------------------- <br /> (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 /> County Ordinances, State Laws,,cnd 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;,l shall not employ any person in such manner <br /> as to become subject to Workman's Compensytion laws of California." <br /> Signed ------- ��` ---------�- Owner .,, <br /> --- -- <br /> BYf" -------------------- --------------- Title - L,�--------- ------------------- <br /> (If other thanown <br /> l FOR DEPARTMENT USE ONLY'- <br /> APPLICATION ACCEPTED BY ka------------ ---------------------------- ------ --- --- - '_. DATE :�`�-��---------- - <br /> BUILDING PERMIT ISSUED --------=r--------------------------------- -------------- --- -- --DATE ---- --------------------------- <br /> ADDITIONALCOMMENTS --------- 1--------------------------------------------- ----------------------- --------------•----------------------- --------------------------- <br /> r <br /> -- - -- -- - -------------------------=------- -------------------- -------------------------------------------- <br /> VJ----------- ---- <br /> Final Inspection b Date - ~--c� - - - - ----- <br /> y <br /> - - - -- --- -- <br /> PY } --------------------- - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'S8 Rev. 5M <br />