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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> z . <br /> ..---�------------ - --------•-------------------- Permit No. <br /> (Complete in Triplicate) <br /> ---------=----------------------------------------------- <br /> This Permit Expires ] Year From bate Issued Date Issued --- <br /> -__--_----------------------------------_---_---- <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 /> y <br /> JOB ADDRESS/LOCATION _.-y`� =/-�` I` � ------CENSUS TRACT -------------------------- <br /> Owner's Name ---��/�1 lJ----l�--- 6._41__ ,9X_ �7~ �'��ll� Phone <br /> Address /7 ,L / , ----- -- - --. Cify - ------- <br /> Contractor's Name - TU.--.-- a -i---- +- -----------------------------------------License #c27/ _ Phone r.-�� <br /> Installation will serve: Residence pt7 partment House❑ Commercial ❑Trailer Court ;❑ <br /> rr Motel F-1Other -------------------------------------------- <br /> Number of living units:--1.-_---- Numberof b dro/oms ---2 -.---Garbage Grinder -�°---- Lot Size --__-_--------------------_--_------_-. <br /> Water Supply: Public System and name - ------ --- ----------------------- Private E] <br /> A. <br /> Character of soil to a depth of 3 feet: Sand❑ Silt E] Clay Peat E] Sandy Loam [] Clay Loam El <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 septic 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 /> r <br /> Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ---------------------- - <br /> LEACHING LINE [ J No. of Lines ------------------------ Length of each line--------------_-----.------ Total Length -------------- ------------- <br /> 'D' Box ------------ Type Filter Material --------------------Depth Filter Material --------------------------------------------Z <br /> Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line ------------------_---M <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No IQ <br /> Water Table Depth ----------------------------------------------.-Rock Size -------------------------------- o <br /> Distance to nearest: Well --------__----------------------------Foundation -------------------- Prop. Line ...................... ' <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) <br /> Septic Tank (Specify Requirements) --------------- --------- ------------------------------------------------------------ ---------------- <br /> posal Field (Specify Requirements) = `f 'Q �-- `---- " � <br /> 7------------------------ <br /> 41 ---------------------------------- <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. 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, I shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed ----- ------------------------------------------------------------------------------ Owner <br /> Titfe ----------------------- <br /> other than owner) <br /> O X FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ---------------------------------------------------- --- ------------ ------------------------- <br /> -------------------------------------------------------- --------------. DATE n -------------- <br /> BUILDING PERMIT ISSUED -.- - ------_ -DATE --------------------- <br /> - - <br /> ADDITIONALCOMMENTS ------------------------------------------------------------- --------------------------------------------------------------------------------------------- -- ' <br /> f <br /> -------------------------------------- ----------------- ---------------------------- ----------------- ------------- <br /> ---------------------------------- --- - - -- ------- - - ---------------- -------------------- <br /> - - - <br /> ----------------------------------------------------- -- ------ ------ -- -- --- -- ----- {{ l.� <br /> Final Inspectian b Date -1. -�"l <br /> Y- --=- -- - ---- ------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> I <br /> E. H. 9 1-'6$ Rev. 5M <br />