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FOR OFFICE USE: <br /> a APPLICATION FOR SANITATION PERMIT <br /> --------------------- Permit No7�"�//--.- <br /> ---- <br /> (Complete in Triplicate) <br /> if <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 exiffing Rules and Regulations: <br /> ` ..— Ir, <br /> JOB ADDRESS/LOCATION -----------------6--nc/ ------------------------------------------------------CENSUS TRACT _----------------•-------- <br /> Owner's Name ----------------- I ,e- ' ----------------------------------------------------------- --Phone ----------- ------------------------ <br /> Address �d!d ----------------s--------------------------------------------------- City 1 <br /> Contractor's Name __- e ------------------------License # - Phone4l` / <br /> r -, ftk- . " 1. I <br /> Installcatton will terve:—�"'~� Re+denceJdApartment Houser Commercial ❑Trailer Court ,❑ <br /> Motel ❑ Other------ 4------------------------------- <br /> Numberiof living units:---'ANumber of bedrooms -A------Garbage Grinder Q._ Lot Siie _______________ <br /> Water Supply: Public System and-name ---- 1/ ,__ c''___t �'f' �C _.`__ ____________________________Private El <br /> Character of soil to a depth of 3'feet: I Sand' Silt 0 Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ <br /> .01 Hardpan ❑ Ad ;e Fill Material ------------ If yes, type ___________________________ <br /> (Plot plan# ihowing size of lot location of,system_.in relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: <br /> {No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> Ir <br /> PACKAGE TREATMENT--[-]---SEPTIC TANK-[-] Size__---------` ---------------------------------- Liquid Depth ----------_--------------- <br /> Capacity --------------- TYPe -- -�-.. ..---- Materials�---� ------ No. Compartments ---------------------- <br /> Distance to nearest: Well ------------------------------------Foursdation Prop. Line ---------------- <br /> •.-- <br /> LEACHING LINE [ ] No. of Lines ---------�"~-I------ Length of each line-7____________ __________ Total Length _________ _. <br /> -_-. ------------ <br /> 'D' Box ------------ Type Filter Material --------------------Depth Filter Material ------------------------------------------•- <br /> Distance to nearest well _______________________ Foundation ---------------------L-. Property Line _--__--____-_____._.___ <br /> SEEPAGE PIT [ ) Depth -------------------- Diameter ________________ Number ----------------------- --- Rock Filled Yes ❑ No 0 <br /> W,ater:`Table Depth ------------------------- <br /> ------------------••---Rock Size ----------------- .......... <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line -----------...:..---.- <br /> REPAIR:/ADDITION(Prev. Sanitation Permit# ____________________________________________ Date --- ------------------------------ <br /> Septic Tank (Specify RequireIments) ---------------- - - <br /> Disposal Field (Specify Requirements] - ___F, _ ___ e`, _ ___ � l/7._!a`y-e-11- -________ <br /> ti _ <br /> ----------------- ------------------ <br /> ------------------------------------------------ -------------------- ---------------------------------------------------- ------------ ---------------------- <br /> � {Draw existing and required addition on'reverse sideY'R— \3 - <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with Son­ 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: - <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.' , 'r y N <br /> Signed Owner <br /> ------------------- <br /> - <br /> BY --------------------------------- - � ----------------- -Title _. <br /> (If other owner) I <br /> FO//R DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY '_ --------------------------------------------- DATE ------- -- - �1 <br /> _. <br /> BUILDING PERMIT ISSUED -----�------------------------------ r----------- --------- <br /> ------------------------------------DATE -------------- --------------------------- <br /> ADDITIONAL COMMENTS -------------------------------------------lY_-_------------------------ -------------------------------- -- <br /> ---------------------------------------------------------------- <br /> __________________________________________________________ <br /> _______ _ __ <br /> _____________--______.-____--_.--__.______-______._____.____._______ <br /> _.__________.---------------.---------------- <br /> --------------------------------------------- <br /> ______ _ __ <br /> Final Inspection by: ------------- ------ --- ---- - �---- --- - -- ---- ------------------Date <br /> -------- <br /> SAN JOA9IN L AL HEALTH DISTRICT a <br /> E. H. 9 1-'68 Rev. 5M <br />