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FOR OFFICE USE: <br /> :�. <br /> ---------------------------- APPLICATION FOR SANITATION PERMIT.. Permit Na. <br /> (Complete In Triplicatel <br /> •..... <br /> ................................ This Permit Expires I Year from Date Issued Date Issued .......... <br /> Application is hereby made to the Son 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. 5:49 and existing Rules and Regulations: <br /> f= � <br /> JOB ADDRESS/LOCATION ..... /a .°__ �Yy_w!�x...... CENSUS TRACT <br /> ............. ... <br /> Owner's Name .�t y -._...-..�._ .. t, L — Phone <br /> Address S'� a S /3vg«css l,aaP----- ..................city . 'Y ..... .... <br /> .._.... ...... <br /> Contractor's Name Ay Th o Ny rt SaN /G6 '57 { <br /> License # Phone -; y'� <br /> Installation will serve: Residence®Apartment House E] Commercial ❑Traller Court <br /> Motel ❑Other -------------------------------------------- <br /> Number <br /> - ---- •-•--- <br /> Number of living units:..-_S_._._. Number of bedrooms ._3.......Garbage Grinder .... Lot Size .... .. ........`e�............... <br /> Water Supply: Public System and name Private <br /> Character of soil to a depth of 3 feet: Sand 0 Silt Q Cloy [J Peat❑ Sandy Loam Q Clay Loam a <br /> Hardpan ❑ Adobe 0 Fill Material ............ If yes,type ............... ............ j <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.l <br /> NEW INSTALLATION: lNo septic tank or seepage pit permitted if public sewer is available within 200 feet) x <br /> PACKAGE TREATMENT [ ] SEPTIC TANK I Size..........t Q `............. Liquid Depth ....... <br /> Capacity --jType Material ----- No. Compartments ..A................0 <br /> Distance to nearest: Well ° ... Prop. Line ° <br /> ------�5�-�•-•'�•--...._....Foundation ...�....`.......... ...:�.............. <br /> LEACHING LINE [ ] No. of Lines _.___.�______________ Length of each line............................ Total Length ---Al........... <br /> 'D' Box ----!------ Type .Filter Material cc k......__Depth Filter Material ...... d I" <br /> Distance to nearest: Well ..... Foundation ...a.V.............. Property Line ......p.....--- <br /> SEEPAGE PIT [ Depth .................... Diameter ________________ Number ....................,....... Rock Filled Yes ❑ No <br /> Water Table Depth ------------- --------- ------------------------Rock Size •--------.... .................. W <br /> Distance to nearest: Well ----------------------------------------Foundation ..___.. ............ Prop. Lin$ ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit+# ............................... ............ Date ..--- .................. <br /> SepticTank (Specify Requirements) ...........---------------------------------------------------------------------------------------------------------......_-- --------_--- <br /> Disposal <br /> --- _---Disposal Field (Specify Requirements) ----------------- --------........................................................___------------ _•,-------------- <br />` --------•----••--•--•••..........- ---- -----------------------------•--------------------------------------------- ................................................. <br /> --•----------------------------------------- ------------ - - - ......... ­---------- ------ --•........................................ <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that 1 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 licew <br /> sed agents signature certifies the following: <br /> I "I certify that in the performance of the work far 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." ,l <br /> Signed .. ,�-_/n��'/#caw '� 5o�Y Owner chi <br /> 13y _..__. . _ ------------------------------------------------- Title ...... <br /> (€f of Fer;&2�neri— <br /> FOR <br /> DEPARTMENT USE ONLY _ <br /> APPLICATION ACCEPTED BY ------ ` ------------•----------------•- --------------------------------------------------- DATE ............... <br /> BUILDING PERMIT ISSUED -------- ----- ----------------_._-.__-- .- - ... � 1 DATE -----.__..._.----------_ ................ <br /> ADDITIONAL COMMENTS .. ..................... ................ <br /> -----•-- ..._...-. ----- <br /> -----....... •---•----------•_... ................. ...........-------------------------------I——-------------- --------- ...... <br /> -----------------------•------------- .. ------------------- ------ - <br /> Final Inspection by: _.. �-----•- ------ --------••....... ............•.Date -V? <br /> EH 13 2a 1-68 Rev. 5M SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7& 3M <br />