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FOR OFFICE- USE- - : ' '� APPLICATION FOR SANITyATION- PERMIT <br /> -------------------- -- -- ------ - Permit No: 00-159J-1 <br /> ----------------- <br /> (Complete in Triplicate) <br /> This Permit Expires 1 Year From Date Issued <br /> Date Issued <br /> ----------------- <br /> ----------------------------------------- --------- --_- <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work1herein <br /> described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> 1 <br /> JOB ADDRESS/LOCATION _/VK/to-------_AW-4 la.....?0 -------CENSUS TRACT ......................... <br /> Owner's Name /SlQ 1t'!l --------------------------------------- - ---- ---- Phone <br /> Address - - 0 > i�-�t��Sh L _ %CityQ G t/ <br /> Contracto).'s Name -- Y-- -- � ---- 0o.License # �f.Xl6�_ __-- Phone ______ri____-_-•- ! <br /> _ �� , <br /> Installation will salve: "ResidenceXApa`rtment House❑ Commeraal ❑Trailer Court'❑ <br /> 11. Motel Other k vA'/S' <br /> Number of living,units:.__�_-__ Number of'bedrooms --_ --.Garbage Grinder Lot°S zi e - --------- ----° <br /> Water Supply: Public System and name ------------------------------------- - -----------------------------------. ` Private ❑ <br /> Character of soilto a depth of 3 feet: 5and'❑ Silt❑._ _ C1 _❑ Peat❑___San LoamQ❑ °Clayytoam%® <br /> Hardpan ❑ Adobex Fill Material ------.--___ If es, type ---.-.s-____y t J <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc, m strbe placed ont r"verse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available wit <br /> hin 200�fee#,)'' f^ <br /> PACKAGE TREATMENT [ ] SEPTIC TANK[ I Size_________________-_-__------ - -- •-4EE`------ --- Liquid", DepVth�r.a.-t- � <br /> k�----------- <br /> ----_.Capacity --------------- - Type -------------------- Material-------------------I-- No. Compartmentsl <br /> Distance to nearest: Well --------------------------•---------Foundation ------------- --------Prop. Line,`__11------ <br /> -----..---- <br /> LEACHING LINE [ ] No. of Lines ------------ ----------- Length of each line__----_---_____---_-.--- Total Length ._ ,---_.-_-_-_--. �rl <br /> 'D' Box --- ------ Type Filter Material _--__--------------Depth Filter Material 6 r----_ _-----=5:----- <br /> Distance to nearest: Well ________________________ Foundation ------------ _--------- Property Line T-------------------- <br /> SEEPAGE <br /> - -------------SEEPAGE PIT [ ) Depth ----- Diameter ---------------- Number -- ------------- ---------- Rock Filled! Yes ❑` �No 0 <br /> io r F i <br /> Water Table Depth --------------- -------------------- Rock Size _ .... _ y k <br /> Distance to nearest: Well ----------------------------- -----Foundation :-------------- - Prop Lm ----.•------••- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ------------------------------------------ Date ------------ ----•-----------::-- <br /> SepticTank (Specify Requirements) -------------0------ ------------------------------------------------------=------------- --------------------11---------------------------- <br /> - "� i /disc' �M <br /> Disposal Field (Specify Requirements) /arG�'lia�`r ------- 1�------ I -�- <br /> --------------------------------------------- - --------- <br /> ----- ---------------------- <br /> - -- --------------------- <br /> ------------------------------ -------------------------------- <br /> exiAt.ing_and required_addition-on_reverserside) <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:-w- J`j <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 i <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed ----- --- Owner <br /> ---------------- <br /> BY <br /> Title _ .......... <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -- - -"--- -- - �---------------------------- --------------------- ------- DATE ------ <br /> BUILDING PERMIT ISSUED ----- ------- ---------- ------------------------------------------------------------------------DATE ------------- ----------------- ----------- <br /> ADDITIONALCOMMENTS ------------------------------------------------------------------------------------------------------- -------------------------- ----- ---------- <br /> - ------ -------------------------------------------- ---- ----- --------------------------------------------------------------- -------------------------------- <br /> I <br /> -------------------------------------------------- <br /> 3 <br /> Final Inspection by: ---------"'�----� + - -------. -- -------------------------------------- ----------------------------Date -- "` "~ --- <br /> SAN <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> i <br /> ' 1-'68 Rev. 5M = ` <br />