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y <br /> FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> --------------------------------------------------------- <br /> Permit No. <br /> 'r.tp------.---------------------------- <br /> (Complete in Triplicate) <br /> Date Issued <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 /> described This application is made incompliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION _�U ._ i �--`'_' -- �'``'`' R`�T / RCENSUS TRACT -------------------------- <br /> i <br /> Owner's Name" _,_ '- -T/�cC- ---------------------'------------ J Phone <br /> Address v --------------------------------- City <br /> ---------------------` 3 ----- <br /> License # Phone - <br /> -•"----- <br /> Contractor s Name ----------------- -----. <br /> Installation will serve: Residence Apartment House L❑ Commercial :❑Trailer Court 'E] <br /> –Motel ❑ Other -------------------------------------------- <br /> Number of-hvirig'units:"-_-1'--'–'Num ber of bedrooms _,-3-------Garbage Grinder ------------ Lot Size -.-4t'!-` $ -------------------- <br /> Water Supply: Public System and name ----------------------•---------•--- ----------~-------------------•-•------------------------•-------------Private <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ® Peat E] Sandy Loam ] Clay Loam E] <br /> Hardpan ❑ Adobe ❑ Fill Material ----- If yes, type ---------------------------- <br /> (Plotplan, 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 availablewithin 200 feet,) I <br /> PACKAGE TREATMENT [ ] SEPTIC TANK ( ] Size----------------------------------------`---- -- Liquid Depth --------------------------- <br /> Capacity -------------------- Type -------------------- Material---------------------- iNo Compartments ------ -------------- <br /> Distance to nearest: Well ------------------------------------Foundation -------- —. _drop. Line ----------...___....._ <br /> LEACHING LINE [ j No. of Lines ------------------------ Length of each line---------------------------- Total Length ----------- ----------- <br /> 'D' Box ------------ Type Filter Material --------------------Depth Filter Material' = -------------------------------- <br /> i <br /> __i Distance to nearest: Well ------------------- -_-Foundation ------------------------- Property Line ------------- <br /> 4� <br /> SEEPAGE PIT Depth -------------------- Diameter _--_--_-_-i_-_-- Number ----_____----_--_______---- Rock Ei11ed Yes ❑ No 0 <br /> Water Table Depth ---------------------------------------- -------Rock Size <br /> Distance to nearest: Well __-___.--_----------------- ._Foundation -------------------- Prop.. Line ------ ............... <br /> I REPAIR/ADDITION(Prev. Sanitation Permit# ---------------------------------------- Date --------------••---------.-.------} <br /> Septic Tank (Specify Requirements) -------- ------------------------------------------------------------------- ��..� - ---• •--------------- ----------- <br /> Disposal Field {Specify Requirements) ---_-__-_. F ----- -- <br /> 41 11 IL <br /> tc ` -------------- -- ------------ ---------------------------------------------- <br /> ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> (Draw existing and required addition on reverse <br /> I-hereby certify'thaf 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, 1 shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed Owner <br /> � n e <br /> By ---k-------- ------ `TJ � A�'•i�h.l--------------- <br /> (If other than owner) <br /> J Title" <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ------ ---------------------------------------- ------------------ DATE --adrr�� <br /> ----- 9 ----- -----------.------ <br /> BUILDINGPERMIT ISSUED ------------------------------------------------------------------------------------------• -------------DATE ------------------------------------------- <br /> ADDITIONALCOMMENTS ------------- ------------------------------------------------------------------------------ --------------------------------------•---------------- --------- <br /> ------------- --------------------------------------------------- ---------------------------------------------------------I----------------------------------------------------------------------------- <br /> ------------------------------------------ - - - --------- -- ---------------------------------------------------------------------------------- <br /> Final Inspection by: - ---- - -------- ------------- • ------------ -- ------------------Date --G Q+ �---------- -- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />