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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT �j <br /> 7-------------------------------------- Permit No. <br /> ----------- <br /> ---- (Complete in Triplicate) <br /> - <br /> 4--,-A4 <br /> ---- - Date Issued _ b <br /> ---------------------______________------_--------------- This Permit Expires 1 Year From Date Issue <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 complignop with CoVnty Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION/`­­�­­ -,r__,4tl-fr/_'!I.�1_101&"-__r�--% 1P&7_0,t-,& .)_CENSUS TRACT -__-__________-.._...--- <br /> Owner's Name/?/-tf-S,.__/V i' .2 -----C,----- ---5 ---------------- --------------------- ------ <br /> -------------------Phone <br /> Address ----- . y. •t ._ i ----------------------•--. City 7/ .r ° f`----------------- ........................... <br /> Contractor's Name ------------------License # -: '-_ Phone _ -. ........... <br /> Installation will serve: Residence [l-Apartment House❑ Commercial ❑Trailer Court ❑ <br /> Motel ❑Other -------------------------------------------- <br /> Number of living units:---/------ Number of bedrooms __-------Garbage Grinder 011"o___ Lot Size ___ _ �_ ` �=_<_,__---- __._ <br /> Water Supply: Public System and name ------------------------•--•-------------------•-------•------•----------------- ------------------ -----------Private , <br /> Character of soil to a depth of 3 feet: Sand'Et"`iiltQ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <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 i p#icgsewer is available within 200 feet,) <br /> [ [A! Size- X/ --t�8 <br /> PACKAGE TREATMENT SEPTIC TANK ______ Liquid Depth _ ___.________________ \ <br /> Capacity 42_ry----- Type C-:_2 __ MaterialGW No. Compartments ................ <br /> Distance to nearest: Well _ �- C�_---__________________Foundation _A1�__----__-.-___ Prop. Line - ......... �V <br /> LEACHING LINE [ No. of Lines -----l---------------- Length of each line---1;1P --------------- Total Length -©_----__---__--_--_--- yDy <br /> 'D' Box __ ---- Type Type Filter Material/6©_ck-_____-Depth Filter Material A9-Ar-------- <br /> Distance to nearest: Well ________ Foundation ------------- Property Line/-:?_4_ <br /> in ------------­-­ <br /> SEEPAGE <br /> -�..-_.__... <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ________________ Number ---------------------------- Rock Fillf'd Yes 'Q No i❑ <br /> WaterTable Depth ------------------------------------------------Rock Size ------------------------------- <br /> Distance to nearest: Well ________________________________________Foundation ------------ ------- Prop. Line ---------------------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ____________________________________________ Date __-______-__________----_-----____) <br /> Septic Tank (Specify Requirements) ------ <br /> Disposal Field (Specify Requirements) G'J! -------- - -- <br /> C <br /> SGSTi__M�' � `AG-�--- ----�-�- � �f-��. - --�--- ', 1 'AG�-�//�'.�.�G� <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 for which this permit is issued, I shall not employ any person in such manner <br /> as to be subject to Workman's Compensation laws of California." <br /> Signed �--------------- -- - ----------------------------------- Owner <br /> Y -------- �-��----:.���,�'---- ----------------------------------------------- Title --- 6 ..P4 -•---- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY --------- <br /> ------- -------------------------------------------------------- DATE ,�' ------------------ <br /> BUILDINGPERMIT ISSUED ----------------------------------------------------------------------------------------------------------DATE ----------------------------------------- <br /> ADDITIONALCOMMENTS ----------------------------------------------------------- ------------------------------------------------- ---------------- ------------------ <br /> ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ------------------------------------------------- ---- ---------- - <br /> Final Inspection b �' <br /> --------------------------------------------.Date ---- ----� -7�-1-�--.--------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />