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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ....._----------------- Permit No. _L . � <br /> (Complete in Triplicate) / <br /> --...._...:------------------- --- -- -- -- -- .!••-: <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 compliances with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION �v-_ �_4a......CENSUS TRACT .......................... <br /> Owner's Name .................._ /�.�l�"-Ov..---- -�/�LL42. 11.................. ...........___......Phone .................................... <br /> Address -------------- Xe .._ ------------------------- City - <br /> Contractor's Name ................. - License # ------- ----- -------- Phone ................... ---------- <br /> Installation will serve: Residence partment House❑ Commercial ❑Trailer Court fl <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 ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe❑ Fill 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 [ ] SEPTIC TANK [ ] Size--- ___--------_------------------..._-..._ _ Liquid Depth .....-_..._- --_-- V� <br /> Ca acit . Type ----- __ Materia!...................... No. Compartments ...................... W <br /> Distance to nearest: Well ------------------------------------Foundation .---------.----------- Prop. Line ....._..._........... <br /> LEACHING LINE [ ] No. of Lines _______________________ Length of each line------- --------------- Total Length <br /> 'D' Box _.. ........ Type Filter Material _ __ __ -----._._Depth Filter Material .................................____ ' <br /> Distance to nearest: Well --.----- _ _. __. _ Foundation Property Line <br /> SEEPAGE PIT [ J Depth .................... Diameter ---------------- Number ............................ Rock Filled Yes ❑ No ❑ <br /> WaterTable Depth --------_....................... .....--------Rock Size ._.............................. <br /> Distance to nearest: Well --- -----------______------------ -----Foundation __..------_......... Prop. Line _.--_____..__.. <br /> REPAIR/ADDITION(Prey. Sanitation Permit# ............____ ----------________ Date ------------ _.------.._-----. -_) � <br /> Septic Tank (Specify Requirements) ___................. ...__ ._`_-_ -. <br /> --- -71 .- ............ -• — <br /> Disposal Field (Specify Requirements) .__.._._. __G'rK'_._�� ---.__-._ __.. - . ____��4,�, ------ <br /> ------------------------------•-•--------------•---.......---•••........-----------------------•--•••-•----••-•._....-- ----------------------------------- ------------......................... <br /> .................................................. - --------- -- <br /> (Draw <br /> (Draw existing and required addition on reverse side) <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. Herne owner or licen- <br /> sed agents signature certifies the following: <br /> "1 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 ----- _ ------- -------- -------------- - -- -----------.------------------ ---------- Owner <br /> By . .. --------- - -- - - -- ----- --- - - - . ...... .... ..... ... ............_ Title _.... --------- ----•---------------- -- ------------ <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY _ <br /> APPLICATION ACCEPTED BY . ----- r_. _._ ... DATE _./'_.:_ _.�_"�lf..._....... <br /> - .......-•---••. . . . <br /> BUILDING PERMIT ISSUED ----- ••... --•.............................................................. .......------DATE ......................................... <br /> ADDITIONALCOMMENTS --•-------------------••----•--------------•----................----•--•-•-•---•--•--.....-------••-•-------...---------------...._--••--...------..---•---- <br /> .....................•--.....-- -----._...................__.................................................................................................................... ---•-------•.._ <br /> .................. ....... ...................... ....................................... -•----•-•----------•-•----------.........-•---•---•--------......-••----•---------- ............-----•......---- <br /> ------------------ ------------------------- - <br /> Final Inspection by: ............. . ..:. C'i +---.—........................ ..-•-- Dote .__ .t�_,7.%.. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />