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FOR OFFICE USE: - <br /> APPLICATION FOR SANITATION PERMIT <br /> • !Complete In Triplicate! <br /> This Permit Expires 1 Year From Data Issued <br /> ..........-----•.......................... .. 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 applicotion is made in complice with County rdinance No. 5 9 and existing Rules and Regulations: <br /> / /J f Z <br /> JOB ADDRESS/LOCAT . �••-&�✓ ........ ....-............CENSUS TRACT .......... - <br /> Owner's Name �...... . 2e --•- .... . ...../�� <br /> Address ---...._._ City ...._. �'•-`- '`-........... ......................... <br /> � <.y --•. '�'�� `� Phone <br /> Contractor's Name --- -•-••'�•----t-- ----------------------�--� •-•----.._...----•--.-...License # ----..-..,.............. •- ----- - �- <br /> Installation will serve: Residence XApartment House Commercial❑Trailer Court 0 <br /> Motel ❑Other...................................:........ <br /> i <br /> Number of living units:..... Number of bedrooms _,3......Garbage Grinder ----........ Lot Size <br /> Water Supply: Public System and name ......................................................... ..Private' , <br /> Character of soil to a depth of 3 feet: Sand b Silt.❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loamy <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 [ ]l SEPTIC TANK ] Size...........................................••••• Liquid Depth .................... <br /> , <br /> Capacity --------------._-... Type Material...................... No. Compartments <br /> Distance.to nearest: Well -------------•......................Foundation ...................... Prop. Line ---..........._...... <br /> LEACHING LINE { ] 'No. of Lines ------------------------ Length of eachline. <br /> *D" <br /> Total length ............................ <br /> D' Box Type Filter Material .....................Depth Filter Material ............................................ <br /> Distance to. nearest: Well ------------------------ Foundation ---.---...--- .......... Property. Line .............••......... <br /> SEEPAGE PIT ( ] Depth .................... Diameter .............-__ Number -_-......................... Rock Filled Yes ❑ No Q. <br /> Water Table Depth ------------•----•---•--•-••---•------ .........Rock Size -................................ <br /> Distance to nearest: Well ........................................Foundation -..........�._-.--- Prop. Line ........._............ <br /> REPAIR/ADDITION(Prev. Sanitation Perm__.... -------------------------• Date ----......... .................... <br /> Septic Tank (Specify Requirements) �------------------ ........ = ... . ... -- ............-- <br /> D' sal ield (Specify Requirements) ....___---- -•-- 3 ~� - `�' <br /> �' <br /> t <br /> -------------- --------- ------------ <br /> k ............ ................. .............. <br /> ----------- -------------------------------- �--- -•--------------------------• --------------------..,._.._...._.. •-•--- --- <br /> r (Draw existing and required addition on reverse side) <br /> I hereby certify that I have pr pared this application and that the work will be done in accordance with San Joaquin <br /> E 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 perfor once of the work for which this permit is issued, I shalt not empi.ey any person in such manner <br /> as to becom ublect to ori an's Compensatio laws offornla." <br /> n " -0varier <br /> Signed + - ----- <br /> ,A- L�. t!�-? - <br /> 3itle _._.0 ..�+.. ........................:......... <br /> {if other than ownerl <br /> FOR DEPARTMENT US ONLY <br /> APPLICATION ACCEPTED BY _.�--------- ---------------- --------------- `;__.:.. DATE -----°} ..-��-._..._._:...... = <br /> BUILDING PERMIT ISSUED ----------------------------_- <br /> DATE <br /> ADDITIONALCOMMENTS --------- --••-------------------_---- -"-"----- .........--•-----•--.. -------- .....................---............................_................... <br /> jU .-i'd��I �'<.,-- - ------------------------ -------------- <br /> -------- -........-.......-......----------------------------------=-----------------.-............................... <br /> I ---------------•.. .......................................... <br /> :.. <br /> `Final Inspection by: . eTRICT <br /> � Date ..... ..-�-.°��' ----........ <br /> EH 13 24 1=68 Rev. SAN JOAQUIN LOCAL HEALT 8/74 3M <br />