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FOR OFFICE USE: <br /> . r APPLICATION FOR SANITATION PERMIT <br /> �f -----__... ...._9=. . - i3 <br /> (Complete in Triplicate) Permit No7- <br /> This Permit Expires I Year From Date Issued Date Issued/d.-. --Q--_:7d } <br /> Application is hereby made to the San Joaquin Lo al Health District for a permit to construct and install the work herein <br /> described. This application is made'in ccomplian with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION ---:/ ?Y <br /> . .....-.•..•....-.. ` ......... -- ---------------------CENSUS TRACT ----------. --_-------. <br /> Owner's Name ........a � • '" �I4V. ..:. ...................Phone �M^lY 3_.-- <br /> . <br /> Address -- Sa,•' ------- - ----------••-•-•- <br /> •-------------- f <br /> } . <br /> 6- <br /> Contractor's Name ._.=N-.•. - ��.: License #I��., I�.- Phone 446 --- <br /> Installation will serve: Res idence;!�Apartment House F1 Commercial❑Trailer Court ;❑ <br /> Motel ❑Other .............. .. ......................... <br /> Number of living units:..----. Number of bedrooms 3-.--__-Garbcge.Grinder ..--_._._-.,,, Lot Size .�p0_--..........���0 ....... <br /> Water Supply: Public System and name .. -- -•.................•-••--•----........-•-•----.....---......w......,-----------•-•--..-.........._.....Private <br /> Character of soil to a depth of 3 feet: Sand:❑ Silt❑ Clay ❑ Peat I] Sandy Loam 0 Clay Loam ❑ <br /> Hardpan ❑ Adobe't Fill Material ............ If yes,type ............................ <br /> (PI'ot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: INo septic tank or-seepage pit permitted if public sewer is available within 200 feet,) J <br /> PACKAGE TREATMENT [ ] SEPTIC TANK.11 -'------------------------- • . ._........_ Liquid Depth -•---........._....--.----• <br /> Capacity ................ Type --••-- . ---- Material.....----------------- No. Compartments ....................... <br /> Distance to neWest: Well _ ................................Foundation ...................... Prop. line ...................... <br /> LEACHING LINE [ ] No. of Lines .frx��� ength of each line---------------- ----------- Total Length <br /> 'D' Box ............ Type Filter Material ....................Depth Filter Material ----------- - + <br /> Distance to i nearest: Well ........................ Foundation ........................ Property Line ..-------_------------- <br /> Diameter ................ Number .._...._ ..._-_............. Rock ❑ (� <br /> SEEPAGE PIT [ ] Depth _.___.'_.._.____ ._ . Rk Filled Yes No C) <br /> � VVV <br /> Water Table Depth ....---•........................................Rock Size.................................. <br /> Distance tolnearest. Well ........................................Foundation ............ Prop. Line w ------ --------------- <br /> REPAIR/ADDITION(Prev. Sanitation;Permit #• •............................•-•---•-.---:-- Date .................................. <br /> 1 . <br /> Septic Tank (Specify Requirements) ...................................................... ---.......... ♦ -------------------------------------------------- <br /> Qisp sal Field (Specif Requ;ements) j6.0_ ��C ('J.-.`�lL--- -- _ _- .- <br /> 05'. ._ ... ... C ./�-�1 -.. --.---. --•-----•-•---•........ ................ <br /> 1(Dra 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. 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 be me subject to orkm 's Compens n laws of California." <br /> Signed .. .. --------•------------- - ` <br /> By ................ .• <br /> ... - • --. ........... ------------------ . . <br /> Title - <br /> (If oth-- -er.tthan owner) <br /> r) <br /> FO DEPAitTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ---- -------------------------------------- DATE �Q- ,�4.-Z�.-•----....... <br /> BUILDING PERMIT ISSUED............ ..................-•--------- ........DATE ................. ......................... <br /> ADDITIONALCOMMENTS-----------------------------------------------------------------------------------------------------------------------------------............................ <br /> ----------•......................................•••....-----•--•-•-.....---------------............_...........------••--.......-----............................................ . ......................... <br /> ..................................................................--•--.......----•---..._._..------. . ------------•--•-----...........---- ................. ...............--- --------•- <br /> -------------•---•--..... ...... <br /> .........-------------------,........----•--•-----------•--............--------•---......••----....... <br /> Final Inspection by: _... _. .:.. V.9�L.. ............................................................•. •. Data /1 �3�.��?__...( .........._.... <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'b6 Rev. 5M <br />