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f� <br /> FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> Permit No. �� <br /> (Complete in Triplicate) <br /> -- ---- <br /> �- Date Issued __! _6 <br /> ----------------------------------- ------------ This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to the ySn'/haquin Local Health District for a per to construct and install the work herein <br /> described. This application is made in. compliance ith County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOC N .. -J7 ?:---�-------------------------------------��----------- -------- S TRACT --------------------•----- <br /> p 4 <br /> Owner's Name �j - ` �- --- ------ ----- ------ - ----- Phone <br /> -------_---- <br /> 1- I <br /> Address -- - -//yam ------ --- --------- ----- --------------- --- - - ------------------------------ -------------- <br /> 7 <br /> -•- --•------ <br /> ----�f p - ------ - - - ---- ---- . city � _ <br /> Contractor's Name .License # __llr ? __ Phone <br /> Installation will serve: Residence Apartment House,E] Commercial :E]Trailer Court !❑ <br /> Motel ❑ Other ------------- ------------------------------ <br /> Number <br /> -Number of living units:----!.------ Number of.bedrooms ------------Garbage Grinder ------------ Lot Size ______�c- - _.. <br /> - -------- - ----- - <br /> Water Supply: Public System and-name ---------------------=----------- ----------------------------------------------------------7------ -------Private <br /> Character of soil to a depth of 3 feet: Sand❑ fi 0 Clay ❑ Peat❑ -Sandy Loam ❑ Clay Loam:❑ <br /> Hardpan. Adobe ❑ -Fill'Material _____ ------ If yes,type ----- ---- --------- --- --- <br /> y W � <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) \ j <br /> NEW INSTALLATION: fNo septic tank or seepage pit permitted if public sewer is available within 200 feet,) FIN <br /> jUr <br /> PACKAGE TREATMENT [ SEPTIC TANK'[ j Size---------------------- Liquid Depth -------------------------- <br /> Capacity -------------------- Type ---------]---------- Material---------------------- .No., ompartments ----------- <br /> Distance to nearest: Well _________________________________Foundation ------------------ --- Prop. Line ______-_.-___:__-----_ <br /> LEACHING LINE [ ] No. of Lines ------------------------ Length of each line-______._._-.__—�30tal—Length ____.--------------------- <br /> 'D' <br /> ___._ _'D' Box ------------ Type Filter - ------- ________ <br /> Distance to nearest: Well ______________________ Foundation _____________________ __-,P_roperty'Line- -------------------------- <br /> SEEPAGE PIT [ ] Depth -_-_-__.____-_____ Diameter ________________ Number _.___ .____________.______ Rock.Filled` Yes ❑ No i❑ <br /> Water Table Depth _ Rock(Size -------------------------------- r <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ---------------------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------- <br /> Septic <br /> ____ - -_Septic Tank (Specify Requirements) -------------------------------------------------------- ` <br /> Disposal Field (Specify Requirements) _________ --- - ______ __________ ; <br /> ---- ------------- <br /> -- � T <br /> 3 -- <br /> _ 3 � <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 Wealth District. Home owner or licen- <br /> sed agents signature certifies the following: „F <br /> "I certify that ' e performance of the work for which this permit is issued, I shall not employ any person in such manner ! <br /> as to bec a su t to Workm Compensation laws of California." <br /> Signed r- --- ---- - ------- Owner <br /> BY ----------- -------- ---- -'--------- ---------------------- Title <br /> ---s <br /> - -------------------------------------------------------- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY = --------------------------------------------------- ------ DATE ---------------- <br /> BUILDINGPERMIT ISSUED -------------------------•-------------------------------- ---- ------DATE --------- ----------------------------- <br /> ADDITIONALCOMMENTS -- ---- -------------------------•---------------------------------------------------------------------------------------------- <br /> -------------------------------------------------------------•------------------------------------------------------- - ---------------------------------------------------------------- --- ' <br /> ------------------------------------------------- <br /> -------------- ------------------------------------------------------------------------------------------------------------- --------- <br /> ------------------------------------------ ----- -- ---- --------------�------- - ---------------------------.------------------------------------------- �> Z <br /> Final Inspection b ------Date ----------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />