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FOR OFFICE USE. <br /> -APPLICATI(_. ^!R SANITATION PERMIT '/Q <br /> --------------------------=----------------------- {Complete in Triplicate} Permit No. _7 d_`_�`�--( <br /> --------------------------- --------------------- This Permit Expires it Year From Date Issued <br /> 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 ._1 _ _ _ __ CENSUS TRACT __________________________ <br /> Owner's Name ' - - Phone <br /> . Address �� Ci ------- :--------------- <br /> ty <br /> Contractor's Name r r 1x? -:� `mss License # -L` Pho -------------------------- <br /> Installation will serve: + Reside ce.[ Apartment House❑.yCommercial ❑Traife�Court ❑ <br /> Motel ❑Other -----------------------------•-------------. <br /> Number of living units:_____5 _--- Number of bedrooms __3__-._.Garbage Grinder lot Size ____________________________________________ <br /> Water Supply: Public System and name -----------------------------------------------------------------------_-------:------------------------------Private 9- <br /> Character of soil to a depth of 3 feet:y Sand'E] Silt❑ Gay ❑ Peat❑ Sandy'Loarn -e Clay Loam El <br /> Hardpan.❑ Adobe'[] Fill Material ----- ------ If yes,type ---------------------------- <br /> s <br /> (Plot plan, showing'size of lot, location of system in relation to wells, buildings, .etc. must-be placed on reverse_side.) Y <br /> NEW INSTALLATION: fNo 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 /> A Distance to nearest: WeIIT------- -------------------------Foundation ----------------------.Prop. Line .--_--- <br /> Len th ofeach line___ Total Length -----.LEACHING LINE No. Lines ------------------- _'---•-._-.--__-- <br /> `h� <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 i❑ <br /> WaterTable Depth ---------------------------------- ----=--------Rock Size -------------------------------- <br /> Distance to nearest: Well --------------- ------------------------Foundation -------------------- Prop. Line ------------------_._ � <br /> REPAIRIADDITION(Prev. Sanitation Permit# -------------------------------------------- Date -------.--------------------------} <br /> SepticTank (Specify Requirements) -------------------------------------------------------------'---------------- ------ -------------------- -------------------------- <br /> Disposal Field (Specify Requirements) - -- _ _ o _ l # <br /> ------ 0 <br /> ' --- (-----r- ,"t ---------------------------------------------------------------I----------- ------ <br /> r <br /> o-- - <br /> {Draw existing and required addition onr <br /> -----�-------------- <br /> reverse side} � <br /> I hereby certify that I have`*epared 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 liven- r <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 id such manner F <br /> as to become subject to Wor an's Compensation laws of California." <br /> Signed --------------------------- ---------- c. <br /> - -- ----- -- -- ----- ------ <br /> By -------------------------------------- ,hra,_e -a_ ,�__: Title. ------5r-.--- ----------------------------------------- <br /> (If other than owner) ci <br /> R .DEPARTMENT OSE ONLY <br /> APPLICATION ACCEPTED B __-t 1_7—k- ---------------- DATE ------- - Z-- --- <br /> -- --- ---------------- <br /> BUILDING PERMIT ISSUED ---------------------------------------------------- ------------------------------------------------DATE -------•----- --------- ------------------- <br /> ADDITIONAL <br /> ------ADDITIONAL COMMENTS ------ G-<--------------------- ------------------------------------------------------------------------------- <br /> -------------------=------------- -----� --^-> X 3-�--------- �-------------------------=•--------------------- ----- ---- <br /> --- <br /> ---- - - -------- <br /> _ ___ _ ____ --.. - • �J__ yam__ <br /> Final Inspection by: �c_ - Date ----------- ! <br /> ---------------- -- <br /> SAN JOAQUINi LOCAL HEALTH DISTRICT ) <br /> E. H. 9 1-'6B Rev. 5M, j <br />