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FOR OFF( USE: <br /> b i< . APPLfv MeN FOR SANITATION PERMIT <br /> Permit No: . <br /> -------------- a <br /> .:_ (Complete in Triplicate) . _ _4 <br /> I - <br /> Date Issued <br /> _ f--------------------_- ---------------- 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 /> a, JOB ADDRESS/LOCATION .r = --------j x Vit- ---------- ----------- ---------------CENSUS TRACT <br /> 1 - - <br /> ` f f _ f -------------- --- ------- --------Rhone.-/ -�..... <br /> Owner's Name - - -� .............. <br /> r <br /> • ��� <br /> . .s r= ---. City <br /> Address -----'-�-- ----------------------------------- --------- <br /> ----------------------------------------- <br /> Phone <br /> --- - -------- --- -- -- - - ---- _ ...._._.. _ <br /> -�f" ^' .`�+^ �!-------------------------- <br /> ------------------ <br /> -- <br /> ! - - �`" License # ' .. Phone <br /> Contractor's Name ._P.__ ._3---- <br /> Installation will serve: Residence [ Apartment House'❑ Commercial:❑Trailer Court 10 t .. <br /> Motel ❑ Other -------------------------------------------- �. <br /> v � r, "fir � � < <br /> Number of living units:_,__,/---__- Number. of_be-drooms __ -------Garbage-Grinder,=�..r.,_._,Lot Size -. <br /> : t _=___ __ -__.�°____________________ <br /> Water Supply: Public System and name ----------------------------------------- ------------------------------ - 3 --------.Private ❑ . <br /> Character of soil to a depth of 3 feet: Sand❑ Silt 0 . Clay ❑ Peat ❑ Sandy loam ❑ Clay Loam .E] <br /> Hardpan ❑ Adobe '0Fill 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 [ I SEPTIC TANK Q ] t Size----------------------------------------------- Liquid Depth ------------------------- <br /> CapacCa <br /> ity ------- Type -------------------- Material---------------------- No. Compartments ------•------•---------- <br /> P Y -------- YP . <br /> ' Distance to nearest: Well ------------------------------------Foundation ----------------------- Prop. Line -----.-------_---•---- <br /> LEACHING LINE [ ] No. of Lines ------------------------ Length of each line--_------------------------.Total Length ---------- ----------------- <br /> i <br /> 'D' Box ------------ Type Filter Material ----------- Depth Filter Material ------------------------------_-----.-•--•- <br /> Distance to-neares#:Well--------------------=----- Foundation:_:----�-------==---Property Line. ---------.-------------- <br /> ' <br /> SEEPAGE PIT' Depth Diameter ------------------- Number-:- : _'--------------------- Rock Filled Yes ❑ No .C] <br /> Water Table Depth ------------------- `-- ------------------Rock Size -------------------------•----- <br /> Distance to nearest: Well --------------------------- ,----Foundation -------------------- Prop. Line ---_..._..___ ........ <br /> REPAIR/ADDITION(Prev. Sanitation Permit#. -----------------!-------------------------- Date ---------------------------.------} <br /> Tank {S ec�f ____________-' <br /> = <br /> -SepticP Y Requirements) __ -------------- ----------------- - -�� -- : <br /> ------ ------- ---------- -- - --------- ----- ----_:� - -----------�, <br /> Disposal Field (Specify Requirements) = ' =--f-:--------'- -- -----' � =-f----= <br /> -----------I------------------------------------------------------------------------------- <br /> ---------- <br /> -------------- --------------------------- -- - A----------------------------------------------------------------------------------------- <br /> (Draw existing and req uired addition on reverse side) <br /> 3 <br /> 1 e work will-be' done in accordance with San Joaquin <br /> hereby certify that I have prepared this application and that the <br /> County Ordinances, State Laws, and Rules and Regul+dtions 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 /> r <br /> as to become subject to War an's Compensation laws of California." <br /> Signed ------ ------ ------------ --------------------------------------------- Owner , <br /> Title 1 <br /> (If other than owner) <br /> a, FOR .DEPARTMENT USE ONLY <br /> 1 ----------------------------------- ' <br /> APPLICATION ACCEPTED BY --- -,---------------- ----- <br /> -----------. DATE ----------gib`�----------------------- ' <br /> --------- - <br /> BUILDINGPERMIT ISSUED --------------------------------------- ----==----------------------=--------------DATE ... --------------------------------------- <br /> ADDITIONALCOMMENTS --------------=------- ------------------------------- --------------------------------------------------------- ---------- ------------------------------ <br /> ----- <br /> -------------------------------------- ------------• ------------------ ---- --------- ----------------------------------------------- <br /> 4 ---------------- --------- -- , ------------- <br /> n <br /> c <br /> Final Inspection by: _f_ t t t Date __.. %-`- --- ------------- -- <br /> SAN JOAQUIN LOCAL, HEALTH 'DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />