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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT �� 3F <br /> Permit No. ----------- <br /> - <br /> --------- ----------------------------------------------- <br /> (Complete <br /> - in Triplicate) Date Issued <br /> --_---____________________________-----_______________ This Permit Expires 1 Year From Date Issued <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 -- 3g6_.�5._� 2 -- ------------------------_� �------.------CENSUS TRACT ------•---------- <br /> Owner's Name ------------C �- L1LQl�fGL =----------- ----------- -------Phone .Ir-6-3-Z3-------- <br /> ---AdAddress <br /> dress ----------- ---------------- --------------------------------------- City -- ----• _< <br /> Contractor's Name ---------------------------- '--------------- --------------------------License # ------------------------ Phone ----------- <br /> Installation will serve: Residence ❑Apartment House❑ Commercial :❑Trailer Court <br /> Motel ❑ Other ------------------------------------ ------- <br /> Number of living units:------------ Number of bedrooms ------------Garbage Grinder ------------ Lot Size _________________________._________________ <br /> Water Supply: Public System and name -----------------------------------------------------------------------------------------------------•---------Private ❑ <br /> Character of soil to a depth of 3 feet: SandEl Silt❑ 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 if public sewer is available within 200 feet,} <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size---------------_------------------------------ - Liquid Depth ------------.__.-..._____. <br /> Capacity ------ Type -------------------- Material_ ---- No. Compartments ---------------------- <br /> Distance to nearest: Well ____________________________________Foundation ---------------------- Prop. Line ---------------------- W <br /> LEACHING LINE [ ] No. of Lines ------------------------ Length of eachline---------------------------_ Total Length ---------------------------- <br /> 'D' Box ------------ Type Filter Material --------------------Depth Filter Material -------------------- ----------------------- 6 <br /> Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line _________________._____ <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No i❑ <br /> Water Table Depth ---------------------------------------- -------Rock Size -------------------------------- <br /> Distance to nearest: Wel! ________________________________________Foundation -------------------- Prop. Line _-_-____--•___--_-----J� <br /> REPAIR/ADDITION(Prev. Sanitation Permit# _________________________ __________________ Date Z4- 9 <br /> Septic Tank (Specify Requirements) ---------- 90-- ----9-1+ r <br /> 1 -----------l�r�--- <br /> Disposal Field (Specify Requirements) ----------------- ---------------------------------------------------------------------------------------� <br /> ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> -------- <br /> ---------------------- --- -- --- - - - -- - -------- ------ <br /> (Draw <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 become subject to Workman's Compensation laws of California." <br /> Signed -------------------------------------- ------ --------------------------- Owner <br /> - -------------------- <br /> /(' 4 ------------- Title ---------------_-- <br /> ------------------------------------------------- <br /> - - ---------------------------------------------------- <br /> (If r than owner) <br /> FOR DEPARTMENT USE ONLY y <br /> APPLICATION ACCEPTED BY __-_ ----------- ------ - - _ - - <br /> -----. DATE ----/ff3 ��/ -•------------------- <br /> BUILDING PERMIT ISSUED -- ----- ---- ---- --------DATE --------- --------------------------- <br /> ADDITIONALCOMMENTS ---------------------------------------------------------------------------------------------------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ------------- - - ------------------- ------- <br /> Final Inspection b ---------,, ------------------ <br /> P Y° ' --------------- "----- Date �` '�Y <br /> SAN JOAQUIN LOCAL HEALT ISTRlCT <br /> E. H, 9 1-'68 Rev. 5M C� <br /> 1 <br />