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T ZOR OFFICE USE: ¢ <br /> AOPLICATION FOR SANITATION PERMITos7 <br /> ..w, iComplete in Triplicatol. Y PermitT� o. i <br /> _, <br /> - Date Issued .Z.-L- <br /> ............. <br /> /- - � <br /> .... This Pennit Expires Ii Year front Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for permit to construct and install the work herein <br /> described. This application Is made in compliance w' County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOC ION ...... ... .......................CENSUS TRACT ...... ................... <br /> Owner's Name -. .. - .. ...... . ........................................ ---Phone ..........-----.._.-..-•---_------ <br /> (97 <br /> Address �..., _ . ---------City.........-......d-_. _ . .......... ---­------------------- <br /> - . <br /> Contractor's Name --------------------•--------:_-.......................... --•-•--- •--•--.._.......•...License# ..................:....... Phone ............................... <br /> Installation will serve: Residence[)i` Apartment House Commercial-OTrailer Court 0 <br /> Motel 0 Other <br /> Number of living units:... Number of bedrooms Garbage Grinder ............. Lot ......... <br /> Water Supply: Public System and name -------------------•-.............._............_......— . ..............r:.:..... `:.:-.".._:Private 1� <br /> Character of soil to a depth of 3 feet: Sand O Silt(_] Clay .0 Peat 0 Sandy'Loom 0 Clay Loam E3 <br /> 3 <br /> Hardpan p Adobe 0 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 slde.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public :ewer IS aval obib`within 200 feet,) <br /> ,PACKAGE TREATMENT ( ] SEPTIC TANK ] Size......... ! Q-- -- ------ ------ Liquid Depth ------ <br /> CapacityType- l ____ Atiteriai:: :. No Compartments <br /> Distance �taffiReorest•- Well /__fib :::Foundation � 7 • _ Prop. Line . <br /> - - <br /> LEACHING LINE [ ] No. of Lines ................Length of each I[..__..:71 <br /> ............. Total Length --I.4. ............... <br /> 'D' Box .... Type Filter Material .../':nf�--f.Depth/filter Material .../.F..'�...,.------•--- <br /> _ -----•. ......... <br /> Distance to nearest: Weil ........ Foundation ......... Property Line ...... <br /> SEEPAGE PIT ( ] Depth .................... Diometer,................. Number _'_.......................... Rock Filled Yes (] No <br /> r <br /> Water Table Depth ...... `� <br /> -•...........:.....:....-----------=----•-=..'..Rock Size .......................... <br /> Prop. Line <br /> ti-- Distance-to nearest:'Well .....'.._-_. - Foundation <br /> REPAIR/ADDITION(Prev. Sanitation Permit+# _ Date ) <br /> Septic Tank (Specify Requirements) ----------------- <br /> ........... .................................... .................... <br /> Disposal Field (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. Home owner or licen- <br /> sed agents signature certifies the following: <br /> "I certify that In the performance of the work f*r`which this permit is Issued, I shall not employ any person in such manner <br /> as t eco biect to orkman' pe, satn' laws of California.-' <br /> Sign --- -----�•--- -- --- .- J - _ Owner <br /> By ------------.-....-- :-....... ------------------- Title ---............ .... .. ------ .......... <br /> (!f other than ownerl L__•_ <br /> DEPARTMENT USE ONLY - ".•� <br /> ,+ <br /> f APPLICATION ACCEPTED BY.---- i ..... ............... DATE. <br /> .-------- •.. .............. ,. r .. L- <br /> . ... <br /> BUILDING PERMIT ISSUED ...... ---------------• ..:.. - _ .... .. ------- ----.......DATE ........................................... <br /> ADDITIONAL_ COMMENTS ------------------- -----•............ ------------------------­- --------•--..... -----------------.-----------------------------------------------•--------•------•--------.------•---- <br /> . <br /> -------------------------------------- <br /> Inspection by: --C---- ---- • •-•...........:...Date ..l .y----------- <br /> EH -W .....- <br /> 3 2L 1-68 Rev. 5MSAN JOAQUIN OCAL HEALTH DISTRICT 8/7h 3M <br />