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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit No: --- <br /> ---------- <br /> -------------- ------ <br /> ----- -- - -------- ----------- This Permit Expires 1 Year From Date Issued Date Issued <br /> -^------_--h <br /> Application i� 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 /> ,i I <br /> JOB ADDRESS/LOCATION <br /> -----------$Y -- ---- - 1'r`! - `� -----------------CENSUS TRACT <br /> } Gr� E <br /> Owner`s Na e -- ---- - - - -------------7-- - ----- --------:--------- hone <br /> Address -------------------- ------ r 0 -- ------ ----- ! City.Y - 4 ------------------------ <br /> Contractor's Name -------- �------------- ----- ---- -=-------.License # --------------- -------- Phone .----- 7. <br /> Installation will serve: Residence ❑Apartment House,❑ Commercial ❑Trailer Court '❑ <br /> Motel ❑Other ----- --- ---------------------------------- <br /> Number of livingunits:---_ Number of bedrooms 22 <br /> ---- -J_---Garbage Grinder ------------ Lot Size-------------- -----••-•-- <br /> Water Supply: Public System and }name:--?-..c------------ -------------------Private <br /> Character of soil to a depth of 3 feet : Sand❑ Silt❑ Clay [] Peat❑ Sandy Loam,-C] Clay Loam% <br /> Hardpan ❑ Adobe Fill Material ------------- If yes,typj'\--------------------------- <br /> w y L -} <br /> (plot plan, showing size of lot, location of system in relation1to 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 /> t <br /> PACKAGE TREATMENT [ ] SEPTIC TANK:[ ] Size------- -----------------------------------_ _2 Liquid Depth --------------------------- <br /> -------___- hllafe—n6l----------------- --- No.. <br /> -- Compartments <br /> Capacity --=�-----._.�.....�....�.�TYpe -------- 'Compartments ------------- ........ <br /> * r <br /> Distance to nearest: Well ------------------------------------Foundation ---- --------------- Prop. Line ---------------------- V}` <br /> LEACHING LINE [ ] No. of Lines ------------------------ Length of each line-----------------:------'---;Tota l Length ------------- -------------- <br /> J Box .` ------ .t�R�^s Depth Filter Material ---- •---•----.- <br /> Type Filter Mater- r,� -r <br /> �� Foundation Property Line <br /> Distance `to nearest; Well --__ __--_---L--___�__ ------------•___•_•_-___ <br /> SEEPAGE PIT [ ) Depth ------- ----------- DiameterNumber p--------------------------- Rock/Filled Yes '❑ No i❑ <br /> Water Table Depth �`------RocklSize ----------------- <br /> y <br /> Distance to nearest. Well --------------�-_ ---------------Foundation ----------- Prop. Line -.------.--- --------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------- ------------ ---------- Date --------------•- . <br /> Septic Tank (Specify Requirements)t ------------------------------ <br /> ------------------------ ------------ ------------------„-------------------------------- <br /> -7----------- <br /> k. <br /> ----------- <br /> Disposal Field (Specify Requirements) ---------- __ --r-- - <br /> ---------------- <br /> -------------------------------- f ---- <br /> f } <br /> X. -'-- -#, - �. - ;--------- --- -------------------- <br /> ------------- <br /> ----------------------------- <br /> (Draw existing and required addition -- -- e <br /> / <br /> • g q ' 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 r <br /> County Ordinances, State Laws, and Rules and Regulations of thfe. San Joaquin local Health,Dis1ri 1. Rome owner or licen- <br /> sed agents signature certifies the foll wing:- ` <br /> "I certify that in the performance of the work 0 which.this'per it is issued, I shall not employ any person in�sucli manner <br /> as to becometio <br /> subjectXto Workman's Compensan laws of CalEf6nia." <br /> Signed --------- ------ ---------- --- _----- - Owner <br /> - ---------------------- ------------- <br /> ry <br /> BY - - #4= Title .-- • <br /> ther t n owner] l rY �, <br /> FOR DEPARTMENTALISE ONLY <br /> APPLICATION ACCEPTED BY --- yr DATE . -: D_ <br /> --------- - ---------- -- ..................... <br /> BUILDIN PERMITAISSUED --------------- -------- - --------------------------------------------------------------=--------------DATE <br /> ADDITIONALCOMMENTS -- --------------------:------- --------------------------------------- -------------- --- ----------------------=--------------------------- <br /> -=-------------- ------------- r'+ rg , - <br /> - I ------ <br /> -------------------------------- <br /> -- ,------- ----------ti-------------------------------------------------------------- ----------------------- ---------- - -'. ----------- <br /> ---------- d <br /> f-------- -------- <br /> --------------------- <br /> Final <br /> ------- <br /> - ---------- <br /> - --------- - <br /> ----- -- ------ <br /> Final Inspection by: }r-__. ----------------------- - --------------------------------------- <br /> Date ----- <br /> SAN <br /> -SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />