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e, <br /> F'OR,OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> I. I.,1� t Permit No. <br /> --------------------------------------------w------------ <br /> (Complete in Triplicate) <br /> ------------ 1------------------------------------------- <br /> issued d - / <br /> i Date Issued - -_/---------------- <br /> 7 <br /> This Permit Expires 1 Year From Date <br /> ------------------ --------------- -----------------------I <br /> ApplicaEy <br /> tion 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 existing Rules and Regulations- <br /> JOB ADDRESS/LOCATION ---------- ------ ------------------------------- -------------CENSUS TRACT ------------ - ------ <br /> I --;I- .— --------------------Phone4�,rZ—_/ - - -------------- <br /> Owner's Name ---- -------------------------,.-0"lex///0------------------------------------------------------ <br /> `2 7e, <br /> /F Z <br /> Address -----------� 0.....Z W- 0--------------------------------------------------- City ---------------------------------------- <br /> ----- Phone,/ <br /> contractor's Name ---11 ------�51_e -.License <br /> ---------------------- ------ # <br /> Installation will serve: ResidencejZ Apartment House-D Co6imercial DTrailer-,Court <br /> ------------------------------------- <br /> Motel E]other <br /> Number of living units-.1-------- Number of bedrooms ___-____Garbage Grinder/-;/o----. Lot Size -3- ------ -------------- <br /> Water Supply: Public System and name --------------------I------------------- --------------------------------------------------------------------- <br /> -Private El <br /> I <br /> Character of soil to a depth of 3 feet. Sand'El Silt F-1 ,Clay [] Peat [I 'Sandy Loam F] Clay Loam.E] <br /> Hardpan F-1 Adobe ❑ Fill Material --------I---- 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 /> N EW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT SEPTIC TANK Size------------------------------------------N- Liquid Depth I---------------*---------- <br /> I Capacity -------------------- Type -------------------- Material---------------------- No. Compartments --------------- <br /> Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop._Line ----------------- <br /> LEACHING LINE No. of Lines ------------------------ Length of each line---------------------------- Total Length .----------•-------...-. <br /> !1 'D' <br /> ---------- <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 C] No 0 <br /> 0t - <br /> WaterTable Depth ------- ----------------------------------------Rock Size --------------------------------- <br /> Distance to nearest. Well ----------------------------------------Foundation -------------------- Prop. Line ------- -------------- <br /> REPAIR/ADDITIONI (Prev. Sanitation Permit°# -------------------------------------------- Date ---------------------------------- <br /> 11 Septic Tank (Specify Requirements) ----------------------------------------------------------------------------------------------------------------------------------------------- <br /> Ia � o-r--- ---- ------------ <br /> Disposal Field {Specify Requirements] - y . <br /> ---------------------------------------------------- - ------------------------------------- <br /> --------------- ------------------------------------------------------------------------------------------------------------------------------ --------------------------------------------------------- <br /> El <br /> (Draw existing and required addition on reverse side) <br /> I 1hereby certify that I have prepared this application and that the work will be done in accordance with Son Joaquin <br /> C:ounty Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or liven. <br /> sed agents signature certifies the following: <br /> ,7 employ any person in such manner <br /> 'I certify that in the performance of the work for which this permit is issued, I shall not L <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed .../--- -------- - - -----6- -------------------------------------------------------------- Owner <br /> By. ----- ----- - - -------------- --------------------------------------------------------- Title ------------------- --------------- --------------------------- ------- <br /> other than owned <br /> FOR DEPARTMEN:T, USE ONLY <br /> --------------------------- -----7 <br /> APPLICATION ACCEPTED BY ---- DATE <br /> BUILDINGPERMIT ISSUED ------------------------------- --------------------------------------------------- --=---------- ---DATE ------------------------------------------- <br /> ADDITIONALCOMMENTS -- ---------------------------------------------------------- ------------------ ---------------------------------------------w--------------------------- <br /> 0 --- - --------------------- ----------------------- <br /> 'Z� - -_!,�-------- --- - <br /> -------------------------------------- <br /> - - ---- ------- <br /> - ----- ---- <br /> ----------------------------------------------- --------------------------------------------------------------------------------------------- --------------- ------------------ ----•------ <br /> Final <br /> ---------4#inal Inspection by: ---------------------------------------------------------------------------------------------------------------------Date --- ----------------- ---------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT C <br /> 9 l-'68 Rev. 5M <br />