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f FOR OFFICE USE:: APPLICATION FOR SANITATION PERMIT <br /> S,5- 1 /d.,•-a r�-------------- <br /> J (Complete in Triplicate) Permit No. <br /> ----------------- .� <br /> -- <br /> Date Issued <br /> --------------_------------_-----------_-------- ,. This Permit Expires 1 Year)rom 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�� �� Crh LSUS TRACT <br /> - <br /> / . s _Phone Owner's Na /-------- ��----------•-•--------•- --- ------------------------------ <br /> 'kle, --------------• City ---•------ <br /> --------_-_--_-_----�-�----- <br /> --------------- <br /> Contractor's Name --------License # Phone <br /> Address Y5 ! <br /> Installation will serve: Residence ❑ Apartment House`❑ Commercial ❑Trailer Court ;0 <br /> I Motel ❑ Other-------------------------------------------- v <br /> Number of,living units:_________ Number of bedrooms.___-__--Garbage Grinder 6S--- Lot Size�0-V 'PO'` _ "'_______________ <br /> € r Water Supply: Public System and name -----------------------------------------------------------------------•----•------•----- ---------------------Private <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay-Loam;❑ <br /> p 2r--- If yes, type Hardpan ❑ Adobe. Fill Material a---------------------------- <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> i NEW INSTALLATION: (No septic tank or seepage pit permitted if public Itewer is available within 200 feet,) j <br /> TREATMENT [ I SEPTIC TANK�[ iie------X-� '' - -_------_____--x Liquid Depth ----- --- <br /> Material_ <br /> - - ----------- <br /> PACKAGE <br /> Capacity --.1i - --- Type !�"-- Material__ /zif-*No. Cornpartments .s --------- ---- <br /> Distance to nearest: Well _ _-____-_Foundation _- /_��j-------- Prop. Line __:__._-... <br /> �y f -- <br /> LEACHING LINE [�J No. of Lines ----r�------------- Length of each line---/�__7�_'Total Length :,�.$--_-_. <br /> 'D' Box-�(!!S--- Type Filter Material AA."' �6epth Filter Material ----- �� <br /> Distance fo nearest: Well --- ------------- Foundation -.--f Q_-__-__- -- _ Property Line. 47_-_-_ <br /> SEEPAGE PIT J] Depth CP -------__ Diameter ��___-__ Number ----�Z---------------E- Rock Filled Yes)' No i❑ <br /> I � �,/ / <br /> I JV <br /> Water Table Depth ----------- ------------------------ Size -'---{-1��_�____-- <br /> i ! + '� f- / <br /> I Distance to nearest: Well ----- d ------------------------ ® _ _ _ p. Line -_- ... <br /> .Foundation _-� _________ ___ _ Pro ........_ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ---------------------- -----------) <br /> Ill <br /> Septic Tank (Specify Requirements) ----------------=------------------------------------------------------------"=-`=='"'..'-----:----------------..----------------------- <br /> I <br /> -- - -•----•_..... <br /> I t l <br /> ------ <br /> Disposal Field (specify Requirements) 1`---•------------------------•-•---------------------------- -------------------------------------------------• ------- <br /> ' {,t <br /> ------- <br /> -------------------------------- -----=------------------------------�---------------------- <br /> dd " ' <br /> (Draw existing and required aition on reversehs de)-, r ' <br /> I%ereby certify that I have prepared this application-and-that-the worktwill-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.-41;I <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 -------------------------------------------€-----------/------------y-� ------------ -------•- Owner E <br /> BY ---------------- �- i��/ /�'� -/- ----------------------- Title ------- ------------------------------------ <br /> (If other than owner) <br /> I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -------- ' - ----------- - --- ---------------------------� --------------------- DATE -------- <br /> BUILDING <br /> ------BUILDING PERMIT ISSUED ----------- --- �- - -- DATE -------------------------------- <br /> .x <br /> AQi?ITIONAL COMMENTS ----------- - - ------ ------- -----------s-- - S--"-— ------------------------------------------------------------ <br /> --- --- <br /> '` .�!-; _ _- ra � .c '------� =_ v ;u - _- ------ --- <br /> ----- <br /> -' ._��;;; <br /> -----=---------------------------------- ------ ----------- <br /> Fin l Inspection by: ----- -------------------t= --- ----- ---------------- -Date' r <br /> � . <br /> L TM SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H.`9 1-'68 Rev. 5M <br />