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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> 7 / 7 .Sti <br /> (Complete in Triplicate) Permit No. <br /> _- __ _ <br /> 7 <br /> This Permit Expires 1 Year From Date Issued Date Issued '-5 -_- l <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 mdde in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> '1 <br /> JOB ADDRESS/LOCATIONp�- - 3V------ <br /> '1 --- -------------------------------------------CENSUS TRACT ----'Sal------------- <br /> ._ �,� ± 1. <br /> -C"------------------ <br /> Owner's Name <br /> ------------Phone <br /> Address ------------------------------------ i <br /> Contractor's Name -- ��`---a 4?CYPt ---S�c -t'��' .--------- --- - ---License # sa�____g_`�5)------ Phone __y-L-&7 M- <br /> Installation will serve: Residence KApartment House,❑ Commercial Trailer Court i❑ <br /> y f, Motel ❑ Other <br /> Number of living)units:.-------------- Number of bedrooms --c�-- ---- .__ <br /> -___Garbage Grinder �� Lot Size ____ _______________ <br /> ' I a � I <br /> Water Supply: Public System ana name-----------------------•------------------------------------- -- --------------------Private, <br /> - -------------------------- <br /> ` Character of soil to a depth of 3 feet:' -Sand'❑ Sift❑ Cla_y ❑ Peat❑ Sandy Loam .0 Clay Loam ❑ <br /> Hardpan ❑ Adobe- ,,Fill Material A0---- If yes, type ------------------------------ <br /> (Plot <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 /> F <br /> PACKAGE TREATMENT [] SEPTIC TANK [ ] Size------------------------------- ---------------- Liquid Depth -------------------------- <br /> } - <br /> I' �.�SZ►'r'� Capacity s--------------------- Type ------------------ Material--------------- ---- No. Compartments <br /> Distance oto nearest: Wel! ------------------------------------Foundation ---------------------- Prop. Line ----_.---- <br /> LEACHING LINE [ ] No. of Lines ------------------------ Length of each line____-_ __,_____"y __--_.,Total Length --___--____•___________ _ <br /> D' Box '1 Type Filter Material <br /> �r� - YP ------ - - Depth Filter Material ----------------------------•-•-•------___-• <br /> ----- ----- -- <br /> D stance'to nearest: Well ----=------------------- Foundation ---------------_ __---- Property Line ------------. --. ----- <br /> SEEPAGE PIT [ ] Depth ----�---------- --- Diameter --------------} 1---------' -- Rock Filled Yes ❑ No i❑ <br /> Diameter Number __ <br /> Water Table Depth -------------------------------------------•---Rock Size -----1------- `-C, <br /> --- ------ <br /> Distance to nearest: We -------- --------- --------------------Foundation ;-.----------------- Prop. Line ...__.___-____•....... <br /> t ,. -.� 7 <br /> REPAIR ADDITION( rev. Sanitation Permit # ____--------------------::_-- :'`-----.-- Date ---------------------------------- <br /> Septic <br /> ---------------------Septic Tan Specify Requirements) --------- ----------- -------------------------------------- ------------------- <br /> i — - <br /> Disposal Field (Specify Requirements) -----------------------;----------------------------------------------- <br /> - <br /> ---------- epa <br /> ----- <br /> ------------ <br /> -- ; <br /> - ------------------------ - -------- --- -------------------------------------------------------------------------------------------- --------------------------------- <br /> ' (Draw existing'and required addition on reverse side) <br /> 1 hereby certify that I have prepared this application and that :the work will be donein accordance with San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulotions(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 wlilch 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." <br /> Signed <br />`! - - -�'�------ - <br /> BYlC"- t ---------------------i --------------- <br /> -Title _._.. -- ----- - ---------------- <br /> Owner------ - ---- ---------- -- .- ------------------- ---- <br /> ---------(if other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ---- -- ------------------- ------------------------------------------------------------------ - DATE Lf r� <br /> BUILDING PERMIT ISSUED = DAT.E. <br /> ---------------------------- <br /> ADDITIONAL COMMENTS - <br /> - ----------------------------------------------------=--------------------------- <br /> ---------------------------------------------------------- ----------------------------------------------------------------- --- -------- ----- <br /> --------------------------- <br /> - - - -- - - - - - - - - - - -- - <br /> --- ------------------------ -------------------- -- -- ------- -- --------------- ---- - - -- - - ---------------- <br /> Final Inspection by: -IC�� f <br /> ------------------ Date ------------------------------------- <br /> ' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />