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(APPLICATION FOR SANITATION PERW,T <br /> x {Complete in Triplicate) <br /> t I Permit No. <br /> This Permit Expires 1 Year From Date Issued 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/LTION ../, � ...... _. , - ............_.._.-..__,-CENSUS TRACT ......... ............ <br /> Owner's Name � ... ,� ... •-.•. -:.:..... ........Phone --------- .--_----•-------•------- <br /> Address G ' -... _ '<Yn e ---------- - -----• ...._...._..._......... <br /> [ 1 <br /> Contractor's Name --- <br /> - ..License # Phone -•--------__-•---------------- <br /> Installation will serve: Residence Apartment House fff�mmercial❑Trailer Court <br /> } Motel ❑Other ----------------- --•----_--------•------- <br /> Number of living units------------- Number of bedrooms ------------Garbage Grinder _..._....... Lot Size ........---..._..._. -------- <br /> Water Supply: Public System and name -----------•------------------------------• ............___-------------_--___---------------.......Private ❑ <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑' Clay ❑ Peat❑ Sandy Loam 0 Clay Loam ❑ <br /> Hardpan a Adobe❑ Fill Material .-----------If yes,type............... ............ <br /> (Plot plan-, showing. size a# lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> F1, <br /> NEW INSTALLATION: (No septic tank or seep ge pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TAMC Size__✓: 1_E?_`__X_ J---------------_-_ Liquid. Depth V......... <br /> Capacity Jtw-p ra Type _J Material_ � -4�.--- No. Compartments -- --....... <br /> --•-. <br /> Distance.to nearest: Well ------.---1.0.3... <br /> ----------Foundation -----/V _ ._------ Prop. Line ----:q-__ <br /> LEACHING LINE [� No. of Lines --------I------------ Length of each line:-----q.Q.�..--_. Total Length ---L�-�'-�----. <br /> 'D' Box ....I------ Type Filter'Material __.._ -----.-Depth Filter Material ...... ---------------------------- <br /> Distance to nearest; Well ------1._ _ -_ - Foundation ------J-�' •_-•_. Property Line .. --------.- <br /> # SEEPAGE PIT (l'� Depth -- __-- Dia'meter ZIJ--------- Number --------..5............... Rock Filled Yes No Q <br /> Water Table Depth --------------d-E3�-- j <br /> p . -_ _ Rgzk Size �_��._..�(..�..._.._-•_-- <br /> Distance to nearest: Well --------ala__ _____________Foundation ----lc7- -- Prop. tine --+ ,r ------- <br /> REPA1R/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ---_------------------------------) <br /> Septic Tank (Specify Requirements) -•----------I------------------ ----------------------•- - -------------•-_..--------------------=---------- <br /> DisposalField (Specify Requirements) -------------------------------------------------- ----------------------------------------------------------_------•------------- <br /> 2 . <br /> - ------------------•-------------------------•-------------- --------------_-... .................=------- <br /> ` (Draw existing and required addition on reverse side) <br /> 1 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. Hone owner or 1149en- <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 /> as .to become subject to Workman's Compensation laws of California." <br /> + Signed -----------•----------•--•---------- <br /> -----• ------------- Owner <br /> By __---- title <br /> --------------- -------------------- <br /> ------------ <br /> P (if other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BYr ------ - -- --• DATI ..�� z' - <br /> BUILDING PERMIT ISSUED -------------------- ----- ------•-------------------- ------------------ -------- ---DATE ...... ------ - <br /> `-} ADDfTIONAL COMMENTS ...--------r- ------- --------------------------------------------- ----- - <br /> - - ------- ------- ----- <br /> F ------------ ------ -------------------------------- -•------------- ---------------- ...... <br /> Final Inspection b4 Date .. ..-`Z- J-1- - •.---.-- <br /> p y: .. �7 <br /> �� 2 1--b lb SAN JOAQUIN LOCAL HEALTH DISTRICT $/A 3M <br /> EH F <br />