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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> .......... ... .............................. Permit No. .7- /l... <br /> (Complete in Triplicate) <br /> Ah <br /> This PermExp xpires 1 Year From Date Issuer! <br /> Otte Issued .ao-.Io . .- <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. 544 and existing Rules and Regulations- <br /> . <br /> JOB ADDRESS/LOC �7. --- ;_._•.... C:;t "".._...... .. E <br /> Owner's Name "-- ......... .... ... :....-.... <br /> Address . ............. ....f �. -.,.�� .. ... ...... -. City .. ............................ ...........-...--•------ <br /> r <br /> Contractor's Name ---•- 1I.. ..... . .....License +# f -A.3-".-........ Phone'1.............................. <br /> c� Y <br /> Installation will serve: Residence�part+nent House 0 Commercial ❑Trailer Court 0 <br /> Motel ❑Other Is <br /> Number of living units-_l...... Number of bedrooms --- ......Garbage Grinder ...-........ tot Size C ' - "•••••••.•• <br /> Water Supply: Public System and name .................... ...................................................................................I'....Private [� <br /> . ; Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat Q Sandy Loam Clay Loam ❑ <br /> . ., <br /> Hardpan.p Adobe-Q 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 aide.)A, <br /> I NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer.is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK I ] Size__----__---_-__--..__ .............. Liquid Depth <br /> Capacity -------------- ----- Type -...----....----••-• Material---•.....___---__..--- No. Compartments ............... <br /> ! Distance to nearest: Well ...Foundation ......... Prop: Line <br /> LEACHING EINE [ No. of Lines ------------------------ Length of each line...................... Total Length ---.........I.............. <br /> 'D' Box :._.....--.. TyPe-FHter Material ....................Depth Filter Material <br /> ' ---------------------: -- .............. •------- P rty Ine _...................... <br /> � ' <br /> SEEPAGE AIT DepthDiameter Number :-._..................._..... Rock Filled <br /> Distance to nearest: Well .....__ ---------------- foundation Property <br /> { 1 P ----•------.._.. Yes No C <br /> Water Table Depth .......... ----•---------- -•-----Rock Size -------------------------------- <br /> Distance <br /> ------•-- ------Distance to nearest: Well --------------- ....................Foundation ---------------•---- Prop.; Line ---------...........di <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ...............___---------------------- Date ---—-------...............­4 i <br /> Septic Tank (Specify Requirements) --•----_..'-•/•�-. ............................................. <br /> ........................................ <br /> . ....!:... ................... <br /> Disposal Field (Specify Requirements) -< n �tJ w ....... ,.- . .. ._. .. <br /> -- ----- - <br /> ' I <br /> --••-- --------• ................. <br /> V-__ ____ -- -- ------ <br /> - l <br /> _ � ',-�-� --...--••.............................................gip..----:---.._......-.--•--• � <br /> (Draw existing and required-addition on reverse side) 11 g <br /> I hereby certify that 1 have prepared this application and that the work will be done In accordance lwith San Jiaquin�- <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health,District. Home owner-of licen- <br /> sed agents signature certifies the following: <br /> "I certify that in the performance of the work for which this permit is issued; 1 shall-not-employ any person in such manner' <br /> as to become subject to orkman's Compensation laws of California.", i R <br /> Signed --------------------- - ---- -------------------------- - Owner <br /> i <br /> (If other than owner) <br /> s <br /> _ FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY _-- ._--- -------------------------------- <br /> ------- -- --------- --- --- DATE .-Z-�.�,1- - ---.....__,_._.-: <br /> - - -------------------------- <br /> BUILDING PERMIT ISSUED --------------- -----------------------------...DATE -...----...'------ --.._.... ----•---- <br /> i ADDITIONAL COMMENTS ................ -------------- ------------........... .............-................--.- -----.----._:F_..---•---.-__-.-_-..--------- <br /> ------------------- -•-----•-------------• ------ ---•------ ------ -- ------ - ..... <br /> � . . <br /> Final Inspection$y: .. <___.. __ Date -Z--f.dee..- "---------••-- <br /> " EH 13 2L . 1-68 Rev. 5M AN-JOAQII#N LOCAL HEALTH DISTRICT8/743M <br /> .I <br />