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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) <br /> Permit No. .....7 ./ <br /> .......................................... <br /> This Permit Expires 1 Year From Date Issued Date Issued ..:J. 2�-�S' <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 /> GG �. <br /> JOB ADDRESS/LOCATION <br /> ��,,/ <br /> ......_._..�._.._._.. D - --- ................... .. ..... . �/J '�..._.,........CENSIJS TRACT .......................... <br /> Owner's Name ....._ /¢............. <br /> . .. . ..�. /�- -- <br /> ......................................Phon <br /> Address City-------------------------•---• - e <br /> •------.................................... <br /> ,.� <br /> Contractor's Name .... . ........�. ...CSI.� �Q.e�r-----------------.................------------License # Phone 5f7--:7.2, . <br /> Installation will serve: Residence Apartment House 0 Commercial ]]Troller Court Q <br /> Motel ❑Other ............................................ <br /> Number of living units ............ number of bedrooms.e(, ..Garbage Grinder ............ Lot Size ............................................ <br /> Water Supply: Public System and name --------------------.................------------------.------------------.....................................Private <br /> Character of soil to a depth of 3 feet: Sand Z Silt 0 Clay ❑ Peat❑ Sandy Loam fl Clay Loam ❑ i <br /> ❑ . ---... If yes,type -------*-------------------- <br /> Hardpan ❑. Adobe` Fill Material _. -� <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 [ ] SEPTIC TANK f ] Size................................................ Liquid Depth -__.__ ................... <br /> Capacity .................... Type ._.....__.... ...... Material...................... No. Compartments ...................... DQ <br /> Distance to nearest: Well <br /> Foundation Prop. Line _l <br /> LEACHING LINE j ] 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 Q <br /> Aoter Table <br /> Distance onearest Well Foundation ._•-•-------_--_---- Prop.Depth ................................................ <br /> ........................................ p e ...................... <br /> REPAIR/ADDITION(Prey. Sanitation Permit# ............................................ Date ........................____.-----1. <br /> Septic Tank (Specify Requirements) .................. ..... .................... ----....----. ....... ..................._........................... <br /> .. <br /> Disposal Field. (Specify Requirements) .. ..... ........ �..._.f� !1_._.._ r- ....zz_ l> ------------ <br /> ----------------- .......... ...... -----•--- ----------- <br /> Z. <br /> .......................... ------ ------------•-------..................-------. ..................... <br /> ............. -------•- ..................................................................--------------------------------------------------------- ------------------ ....... <br /> Draw existing and required addition on reverse side) <br /> 1 hereby certify that I have prepare this application and that the work will be done ,in accordance with San Joaquin <br /> County Ordinances, State Laws, and ules and Regulations of the San Joaquin Local Health District. Home owner or licen- <br /> sed agents-signature certifies the folio ing: <br /> "I certify that in the performance of th� 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 .----- ------------------------•..................................- ---. Owner <br /> By ............ .af .._ ..�.. ---------------------------....._.. .................... Title .....C�!i. t .......................................... <br /> ( other than owner) <br /> OR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ------- - - <br /> DATE ...... ."/.9.-�.�iJ <br /> BUILDINGPERMIT ISSUED .................................................--_----_- --.--.--------••---------------------•-----._DATE ........................................... <br /> ADDITIONAL COMMENTS ...................................••-•-••---- --••........................... <br /> --------•--••..................... •-•-----•----- -•-•-•--...----••---•-•-•-•-----------.......---.....----.......----------------------•-------.._........�........ ............ <br /> --------------------------------- ................ - ........... <br /> Fina( Inspection by. --•_......... ......................................................Date .......... ...� --•-• <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H.13 241-'68 Rev. 5M 7/72 3 M <br />