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F R OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> = 3s <br /> t� Permit No. -_T02_-_7._____. <br /> (Complete in Triplicate) <br /> o <br /> Date Issued __ <br /> -----,_-_---------- ----------- This Permit Expires ] Year From Date Issued �7L <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 /> - <br /> ------------------- ---- -------------CENSUS TRACT ----------------- -------- <br /> Owner's Name ----�C�'_C --- –c`'-z-`=�-'��= ---- Phone <br /> -- ---- --- - <br /> t. r <br /> 2�-`Address ----------- City =� ------ ----- --- ---------------------------------------- <br /> Contractor's <br /> Name -----$�?--------------- -------- ---------------------------- --------License -- Phone ---------------- <br /> Installation will serve: Residence ®,Apartment House,❑ Commercial ❑Trailer Court ',❑ <br /> } Motel ❑Other ---- ----------------------------------- <br /> Number of living units:-----------! Number of bedrooms uR--------Garbage Grinder r= = Lot Size 6i C r-- --__________________ __________ <br /> Water Supply: Public System and name -------------------------------------------------------------- ----------------------------------------------Private <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ i. Sandy Loam ❑ Clay Loam f] <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 [ ] <br /> SEPTIC TANK 5ize_____� `�______________________ Liquid Depth ----- �.�-______ <br /> f <br /> Capacity 1` -------- Type _ a..> -_ Material Compartments Compartments _ <br /> -------------___ <br /> Distance to nearest: Well ------_-___--___________________Foundation _�n_____.- -___ Prop. Line . ____________...... 1J <br /> LEACHING LINE No. of Lines ----_a_-------------- Length of-each line---_r_S�.ST7------ Total Length !_.________________ <br /> vv /j <br /> 'D' Box - -� Type Filter Material &X----_______Depth Filter Material ...1�1___----------_____�--_-__-____... <br /> Distance torne`arest: Well _--__� __�_______-__ Foundation ---�v___._________ Property Line ______.__._.__._.__ <br /> SEEPAGE PIT [�f Depth -5 Diameter ---- Number ____._ -- Rock Filled Yes 0/No 0 <br /> Water Table Depth ---------G:;;,A------------------------------ -Rock Size ---------- <br /> Distance to nearest: Well __/� __�_______________________Foundation __/- -- __----. Prop. Line _ _. .......... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) <br /> SepticTank (Specify Requirements) _.-------------------------------------------------------------------------------- -----------------------------------------------------... <br /> Disposal Field (Specify Requirements) ------------------------------------------------------------------------------------------------------------------------- ------ , <br /> ----------------- --------------------------------------Y --------------------------------------------------------------------------- ----------------------------------------------------------------- <br /> -----------------------------------------------------------------'--------------------------------t-------------------------------------------------------------------- <br /> ------------------------------ <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that I have prepared thisapplicationand 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: r ` <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 - ----------- ----------------- ------ <br /> - ---- Owner <br /> F <br /> BY - -- ------------------------- ---- -- -`-�----- - �-�'-�--�'�--T-�------------------ Title ------ -- � l� ��-.�------------- ---------- <br /> (If other than caner) <br /> FOR DEPARTMENT, USE ONLY <br /> APPLICATION ACCEPTED BY --- - --- --- -- - ------------ - ----------- DATE _'1`.� -------------------- <br /> BUILDING PERMIT ISSUED --------------------- -0 --------------------------DATE ------------------------------------------- <br /> ADDITIONALCOMMENTS ------------------------------------------------------------------- --------------------------------------------------------------------------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ---------------------------------- ----------------------------------------------------------------------------------------------------- <br /> --------------------------------- -- <br /> Final Inspection by: _- Date --- ..__-- Z �------- <br /> - - -- 2QUIN <br /> - -- --- --SAN JLOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />