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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT o <br /> Permit No. -4j•- <br /> '. (Complete in Triplicate) <br /> Date Issued <br /> ------------- ------------- <br /> -- <br /> This Permit Expires 1 Year From 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 /> pp <br /> described. <br /> This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION --�,:?-5­5-0 �--�--�?-- ---- ---" ""---" --- <br /> "--- --------------CENSUS TRACT ---- ---•--------.. <br /> ' � °cZ _ ------- �.c.�E�r a- --- ---------- --Phone ----------------------------------- <br /> owner's <br /> ----- ---------- ---------•-------Owner's Name ° <br /> - - ----------------- <br /> �Q q Cit -- --�_----------------------------------- <br /> Address <br /> --- --------- --------------------------------••----- <br /> Address ----L1._+-- -._._a --�f----------- Y <br /> ------------- <br /> ' Jr License # -1_�C Phone <br /> Contractor's Name d`. - ----- _; .;' ❑ <br /> Installation will serve: Residence Apartment House❑ Commercial Tra+le Court ❑ <br /> : <br /> Motel ❑Other -- ---------------------,--------------- l <br /> Number of living units:--1-----."_ Number of bedrooms ---3-___Garb,age Grinder ------------ Lot Size ------------------------I-------- •--------- <br /> Private 2 <br /> - ------------------------------------ ------ <br /> Water Supply: Public System and name --------------------------------- ----------- <br /> Character <br /> - --=Character of soil to a depth of 3 feet: Sand ❑ Silt:❑ Clay ❑ Peat❑ Sandy Loam� Clay Loam 'El <br /> I <br /> Hardpan ❑ Adobe'❑ Fill Material ------- <br /> ----- If Yes,type -------------`----------- <br /> ( planIan showing size of lot, location of system in relation to wells, buildings, .efc. must be placed on reverse side.) <br /> , <br /> p seepage pit permitted if public sewer is available within 200 feet,) <br /> NEW INSTALLATION: {No septic flank or / <br /> A <br /> Siz t S"-_------ Liquid Depth ----`'�-----------•. <br /> PACKAGE TREATMENT ( ] SEPTIC TANK' f q p <br /> t <br /> p y �. _-_- Material__ .�__ No. Compartments ----�-------:._-. <br /> Ca acct l Q_ Type l�!!r�'`'a ' ! 5 / <br /> Distance to ne est: Well I------ ____1-0----------- Prop. Line _____"___.--'.-_-_--- <br /> 'k <br /> i �' f ---- ----- Total Length -�`-f--�'-----••------• <br /> --------------- <br /> LEACHING LINE [� No. of Lines ____-, __.----_____._' Length of-each line_._._-- - - g If <br /> _ _ Depth Filter Material 1_`3__•----•--------•-• ----- <br /> Distance to nearest: Welle--_M� l '---- Foundation p , <br /> Type f l G- --.__- Property Line _ <br /> ' SEEPAGE PIT ( Depth _ Diameter <br /> Number ------ -��-------------- Rock Filled Yes ❑ No <br /> ] ------------------- <br /> Water Table Depth __ Rock.Size -------------- i <br /> ---- <br /> 3f y b <br /> t Distance to nearest: Well--_-------- - �.- Foundation •-:----------; --- Prop. Line -------- ............. <br /> --------------- - 1 r <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------- -- % ] <br /> _- ---------------------------�r <br /> ------- <br /> Septic Tank {Specify Requirements} ------------- <br /> Disposal Field (Specify Requirements) ------------------------------------------ ----------------- ---------- -------- ----------- ---i <br /> --- -------------- <br /> -------------------- <br /> - -------------------------=------ <br /> -= - ------------------- ------- ---------------------------- -- e <br /> - --------------------------- - - <br /> ! {Draw existing and required addition on reverse si e) <br /> e with San Joaquin <br /> I hereby certify that I have prepared this application and that the work will be done in accordanc <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or lfcen- <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." r <br /> Signed ----------------- ------ ` --------------------------------- Owner <br /> .._ c'" <br /> Title <br /> (If other than owner) # <br /> FOR DEPARTMENT USE ONLY <br /> DATE --"---------- <br /> i APPLICATION ACCEPTED BY -------- ----------------------------- DATE -------- ----------------------------- <br /> BUILDING PERMIT ISSUED <br /> ------------------------------------------ <br /> ADDITIONAL COMMENTS ------------------------ - ----------------- <br /> ---------------------------------------- =----------------------------------------------- <br /> --------------------------------------- <br /> - <br /> ________________________________________________"____-_______._________- ___.____.______________________________.-"__ <br /> ----. --------------- ._-_____ - <br /> _ / _________________________________________________________f <br /> -------- -- ---- ---- ---- - --- - _____ ____ _ Date --- ----------- <br /> Final <br /> -- <br /> __. <br /> _-__ . <br /> Final Inspection by: - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M --'s':- _ '~ <br />