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FOR OFFICE USE: J �' <br /> APPLICATION FOR SANITATION PERMIT <br /> --------------------- ------- -------------------------- a S <br /> Permit No. _------------------- <br /> {Complete in Triplicate) -1 <br /> ___________________________________.______________.___ This Permit Expires 1 Year From Date Issued <br /> Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a per to construct and install the work herein <br /> described. This application is made in c mpliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION .--- ----___ �1/.......____ --------- --------------------CENSUS +TRRACT ---------------------.._. <br /> Owner's Name ----------------- -�_-- ____-- �i/L Phon 'G __"_Q_ 3�.___--- <br /> - ----------------- --- <br /> Address ------------------------------9/ (:.------- --- =- [------ - ----- City ---------------------------------- ------------------- <br /> Contractor's Name ---------------- ---- _----- ----�--�3_f1 — :-----------------License #� ;5��------ Phone _V-64 �bF <br /> Installation will serve: Residence�_Apartment House❑ Commercial ❑Trailer Court i❑ <br /> Motel ❑ Other ------------------------------------------- <br /> Number of living units:_- �__�_ Number of bedrooms ----- Grinder ------------ Lot Size -.__.i -------.S--- _____________ <br /> Water Supply: Public System and name ---------------------- ---------------------------------------------------------------------------Private <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> �* 1Hardpan ❑ Adobe`Q 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 publicisewer is available within 200 feet,) <br /> PACKAGE TREATMENT , [ 7 SEPTIC TANK f l Size--------------------"--''----------------- ------- Liquid Depth --------------------------- <br /> Capcici'tyf-------------------- Type -------------------1,.Materia l------------- No. Compartments ------------ <br /> Distance <br /> ----------Distnce to nearest: Well ______________ '`5 r___=__;_____Foundation ----------------- ---- Prop. Line ______________________ <br /> LEACHING LINE [.,jam No. of Lines _________________________Length of each .line__-______-_______-___.._____- Total 'Length _____.-_-_---------___-_-__ <br /> 'D' Box ------------ Type Filter__Material ____________________Depth Filter Material ---------------.-___---____-_-.__-___-____._ <br /> Distance to nearest: Well _______ ------- Foundation ------------------------ Property Line ________________________ <br /> SEEPAGE PIT [ ] Depth ---- . ------- Diameter ---------------- Number ___-__.-----------.--------- Rock Filled Yes ❑ No <br /> Water Table Depth � ------ ------------ _,_Rock Size -------------------------------- <br /> Distance <br /> ---------------------Distance to nearest: Well ________________________________________Foundation -----------..------- Prop. Line __--__-_..___-__-__.__ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ---------------------------------_I <br /> SepticTank (Specify Requirements) -------------- ----------------------------------------------------- ---------------------------------•--------------------------------- <br /> Disposal Field (Specify Requirements) ------------ ------ ---------------------r--------- ------------- <br /> ----------- - <br /> ----- ---------------------- ------------------ - - <br /> } <br /> {Draw existing and required addition on reverse side) <br /> I hereby certify that 1 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 sh_all not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed --------------------------------- -------------------------------- -- <br /> Owner <br /> BY � = Title ------- ---- -- -- <br /> (If other t a owner) t <br /> FOR DEPARTMENT USE ONLY <br /> ' ` <br /> - ---- ----------- DATE --- � A-9----- ---------- <br /> APPLICATION ACCEPTED BY <br /> BUILDING PERMIT ISSUED --- --------------------------- ----------- ----------------=--------------DATE ------------------------------------------- <br /> ---------- -- <br /> - <br /> ADDITIONALCOMMENTS -------------------------------------------------------------­­--------- ---------------------------------------------------------------------------------- <br /> --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ---------------------------------- <br /> -------------- <br /> ---------------------------------- ---------------------------------------------------------------------------------------------------------t-a- -3`- ' ' <br /> Final Inspection b u" -- - --------------------------- .Date <br /> P Y; <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M C/j 1 <br />