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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> Permit No. <br /> ­(Completteei Triplicate <br /> -------------------------------------------------- - <br /> This Permit Expires 1 Year From bate Issued Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a per to construct and install the work herein <br /> described. This application is made in compliance with County Ordinance No. 5491 and existing Rules and Regulations: R <br /> ;- ---JOB ADDRESS/LOC T N ------/ h J <br /> r '----CENSUS TRACT .5 <br /> ----F-----€-- Phone . <br /> I-� ---------- <br /> Owner's Name --------- . r <br /> City '�'---------------------------------•----------•--_-- <br /> Address - ----. , <br /> Contractor's Name __ �f �� Phone 7 _-� _6 " <br /> License #�C -tel } <br /> i <br /> Installation will serve: Residence %Apartment House,❑ Commercial :❑Trailer Coujrt Cl <br /> Motel ❑ Other -------------------------------------------- i 1 ' t At <br /> Number of living units:-----/---- Number of bedrooms __--�_Gorbage Grinder ;-- ____�- 'Lot Size ." _"""-��:_.:_"_ ""-_--"--."" - <br /> Water Supply: Public System and name --------------- Private: <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ElPeat Sandy Loam ❑ Clay Loam <br /> Hardpan ❑ Adobe Fill Mateial ------------ If yes,type "----------------------- ` <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc!-m.ust <br /> be-placed-on-reverse side.) \ <br /> f ublic sewer is atiailable.within 20d feet,) <br /> 4 NEW INSTALLATION: (No septic tank or seepage pit perm+tt Ali p ` <br /> PACKAGE TREATMENT [ SEPTIC TANK'[ ] Size_-"-""-_""_".. ----------- ------------------ Liquid Depth <br /> t <br /> •----•-----•--•- <br /> Capacity i Type _ Mafierial No. Compartments ------ <br /> -- Prop. Line ---------- ------ : <br /> Distance to nearest: Weli __" - _--------------------1.Foundation`���_-__f_---- . <br /> Len Total Len <br /> LEACHING LINE [ j No. of Eines ----------------------- gth of each line- - - ----" �- Length <br /> r M <br /> D' Box .#-------- <br /> -- Type Filter"Material ------------------ Depth FilteruMgterial ine _- <br /> E ` * ion Property Distance #o nearest: Well - __.___?�____--F_ Faunda +on 1_.---________________ p ty L <br /> SEEPAGE PIT [ ] Depth __;_ ___ -- D+ameter� Number ---- ------------------- - Rock Filled Yes ❑ No . <br /> Water Table :De th _-_._---- Rock5ize ---". -------------- <br /> Distance o`'nearest: Well --------------------------------- Foundation ----- <br /> ---------_----- Prop. Line -•----...----••--- -- <br /> -------ate �-----------'-----�--%a--�-------} <br /> REPAIR/ADDITION(Prev. Sanitation Permit# --_------_--------"--"_ ---___--- <br /> ' . <br /> Septic Tank (Specify Requirem ts) --------------------------------------------------r f <br /> P Disposal Field (Specify Requirements) ------ �� <br /> - <br /> �_ 3 -- ------ --- _ <br /> ----------------------------- ------- ': <br /> � ----- ------------ ----`---------- -------.- ---- ------------ --------=--------- <br /> (Draw existing and required ad- <br /> .�.-•�..,�.'w <br /> j dition an reverse side) <br /> I hereby certify that Vhave 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 /> j "t+ce�tify.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 /> 4 Signed ------------------- --------- ----------- ----------------------------- Owner <br /> ------------ ----------------- Title <br /> - <br /> (I other n owner) <br /> --FOR .DEPARTMENT USE ONLY <br /> �..7 <br /> ------r-__ _-.:>:------- DATE===7=== /V_-_:_�� ------------ ------ <br /> APPLICATION ACCEPTED BY ------ <br /> BUILDINGPERMIT ISSUED --------- --------------------------------------------= ------------------------------DATE -------------------------------------- <br /> ADDITIONALCOMMENTS --------- -------------- {-------- - ` `- ------------------- -------------------------- ----------- ---------------------- <br /> Ia' .x :',�� i ------- ---------------------------------------------------------- ----------- <br /> ------------ ------------------------ i --, - ----- ------ <br /> -- - ------------- -------------- - -- ------------------------------------------------------------- ------------------- ------- <br /> - --------------------------------------------- ------------ <br /> "-_______""-" - -"__ ."-" -- _ _ ___--_"-______"_""-___-___-""""--- J <br /> Final Inspection by. -- ------- -- -- -------- --- ------------- Date j <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> i <br /> i E. H. 9 1-'b8 Rev. 5M <br />