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FOR OFFICE USE- <br /> APPLICATION FOR SANITATION PERMIT <br /> Permit No. <br /> (Complete in Triplicate) <br /> �6. <br /> ... ............... This Permit Expires } 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 <br /> �.........����.: CENSUS TRACT <br /> Owner's Name ... ���..�!..�..._ � .. A.1 <br /> �C Phone <br /> ••-•-.....�..,-•�•-• ... .... <br /> Address .......... <br /> ... . ...............•..... . .........--•••• ............ City ........ ------------I.....0.... <br /> .• ...... .............. <br /> Contractor's Name ...............Ifty-----.;��P... ...........................................License # ....................... Phone .............................. <br /> Installation will serve: Residence M Apartment House❑ Commercial ❑Trailer Court 0 <br /> Motel ❑Other --•.............................. <br /> Number of living units:....6,__ Number of bedrooms ...2....Garbage Grinder ----- Lot Size .. �''`. ._.l._ � .. <br /> Water Supply: Public System and name ............ .kr1.1..Pq.,,,_.-JV-L.r...........W.. .............................Private <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat❑ Sandy Loam 40. Clay Loam 0 <br /> Hardpan ❑ Adobe (R 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 septic tank or seepage pit permitted if public sewer is available within 200 feet,) '1 <br /> PACKAGE TREATMENT [ ] SEPTIC TANK,t P'e ('i�` Sixe............ Liquid Depth ..-Wil:'.............. ! <br /> --....-----•------. -- <br /> Capacity ---;�•�01ijype � Material_ � -; •s=5.._._. Na. Compartments � <br /> Distance tonearest: JT <br /> Well ..� /1_.: -.-_ ......Foundation .I _Q_. :._-_.- Prop. Line ..2A. <br /> LEACHING LINE [ ] No. of Lines ...... .:.......... Length of each line........�KE.,t��- 'Total Length .....-1... _ ` <br /> 'D' Box ._k<.. Type Filter Material .-.............Depth Filter Material _.-.--/?" ........................... <br /> / y� <br /> Distance to nearest: Well ..l_Q.�..�`"... Foundation -...�.�.',�;�.... Property Line ._.._k?x.�._.t.q_..... Z <br /> SEEPAGE PIT [ ] Depth - :. Diameter _``I;r_�.f._... Number ..--..-._--_--------- Rock Filled Yes No ❑ <br /> Water Table Depth . .... .........Rock Size <br /> = ............... <br /> Distance to nearest: Well ....1.4 ....--.•..-•. ....Foundation Prop. Line ... ...... <br /> REPAIR/ADDI'T'ION(Prev. Sanitation Permit# ............................................ Date ----------------------------------) <br /> O <br /> SepticTank (Specify Requirements) -•--•------•--•-•-------------------------------------- -----------------------•---------..............._._..........._----•------.----- <br /> DisposalField (Specify Requirements) ------ ----------------------- ...............--------------------------------------------------------------------------------------- <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, and Rules and Regulations of the San Joaquin Local Health District. Ham* owner or licen- <br /> sed agents signature certifies the following.- <br /> "I <br /> ollowing:"I certify that inrthe performance of the work for which this permit is issued, I shall not employ any person in such manner <br /> as to become u Iect to Wo kman's Com�en7lon laws of California." <br /> Signed ----- � .� ±J-........ 1 �'�. ---. Owner <br /> BY •---------------- --------------------------------��DEP,4TPAEtgT, <br /> --...........-------- Title --...............------.....................----........................ <br /> (If other than owner <br /> U NLY <br /> r _ u/ DATE ... 0.,.1' <br /> APPLICATION ACCEPTED SY ...s ......... . . ..t..--... ,,�. . ... s. <br /> BBUILDING PERMIT ISSUEDDATE ...............•---.......�.... <br /> ..-•---. <br /> . -•---- -------- ---•------- .. .. <br /> ADDITIONAL COMMENTS .. --- ---- --• .. ....... .........•-----.._.........._.__- <br /> ....................... . .. ... ... ----- �, ..-- �.. <br /> -- . . <br /> ... ....... ------------ ...........---------------------........................................ <br /> FinalInspection by: .. ------ .... ....................................................................................Date _ ......_._.. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H.13 24 1-'68 Rev..5M --_- - 7/72 3 M <br />