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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> Permit No: ----"----�----------- <br />-------------------- <br /> ----- ---------"""--""----- i (Complete in Triplicate) <br /> ..-.......I----------------------------------------------- Date issued �- <br /> This Permit Expires 1 Year From Date Issue '� <br /> -76 <br /> Application is hereby made to the <br /> ___ ------------- <br /> pp y San .loaquin 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 /> ell <br /> CENSUS TRACT - <br /> JOB ADDRESS/1-OCATION ----- <br /> �-------�-------- -------• --------- --....Phone <br /> Owner's Name ------------------------------------------ <br /> cit <br /> �! f ~=- <br /> ------------------ -- <br /> ` f Y <br /> Address __2-- - ----- (� <br /> " License # ��Phone <br /> �. <br /> Contractors Name :._ --- '` - <br /> Installation will serve: Residence �partm6nt-Heuse[]!Commercial:❑Trailer Court 0 <br /> Motel ❑ Other -------------------------------------------- <br /> Lot ---------• <br /> Number of living units:.- ------ Number of bedrooms ...._a?�---Garbage Grinder Lot Size -_---------- ; <br /> i rPrivate ❑ <br /> 'G�- <br /> Water Supply: Public System and name ------ __.�.%_ _l_---- _ t _�r . . _ -- -. <br /> _. Loam � <br /> , <br /> 1 Character of soil to a depth of 3 feet: Sand'❑ Silt n ' Clay Q Peat'❑— Sand y`Loam ❑ Cla Y <br /> Hardpan F-1Adobe F] Fill Material -------- --- If yes,type ---------------------------- <br /> (Piot pltxn;-showing size of lot, location of system in relation to wells, <br /> buildings, etc. must be placed on reverse side.) <br /> p It <br /> seepage pit permitted if public sewer is available within 200 feet,) <br /> NEW INSTALLATION: {No septic tPACKAGE TREATMENT { ] SEPTIC TANK![ ] Size-- . --- _ Liquid Depth _----- -- �• <br /> _ �: y—`-� <br /> f ---------------`� YP <br /> Capacity i- - <br /> T e _� Material.. iC� � No. Compartments 4.------• <br /> Fount/dation --- ---------------- Prop. Line --------- 46 <br /> Dis <br /> nce to nearest: Well ------- <br /> LEACHING LINE ] Notaof Liries�ir� �ll-)Le.nof line_ _�T.- ?`- �L- Total Length i, <br /> LEA [ <br /> v7 . De h�Filter. Material--------- <br /> 'D' Box ---/--"---- Type Filter Material ------------ ---- -- P ?,ti <br /> c <br /> >'..? lDF;> Distance to nearest: Well �` -�--- Foundation -"-,- Properly Line ------------- <br /> t.�.r�" .. � t��;_--- <br /> SEEPAGE PIT L l Depth --- --------------- Diameter <br /> �_�-_ Number -------------------r -Rock Filled Yes ❑ Na C3 <br /> Water Table Depth <br /> -------------------------- - <br /> ---------..Rock Size ---'`------ <br /> 1 '---•Foundation -------------------- Prop. Line -------------------- <br /> Distance <br /> ---- -•-----------Distance to nearest: Well _.. ........ ..... <br /> ---------------- <br /> �� I == Date ---------------------•----y:----1 <br /> REPAIR/ADDITION(Prev. Sonitatioi. Permit#1---------------------- - , <br /> — ( ------------------------- = - <br /> ------------- <br /> i r ------------------ -----------'"-.._ <br /> Septic Tank (Specify Requirements) -------:�----------�- ----- ------------•--_---- <br /> f . --- <br /> Disposal Field (Specify Requirements) ----------------------------- <br /> ------ -- -- -- -- <br /> ' ---------- ----- --- -- --- - --•--- <br /> . <br /> ------.----------------------------- 4 <br /> �.�(Draw existing and reguired`addition on reverse si e `, <br /> I hereby certify that 1 have prepared-ihis�application arid .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 DistrictTHome owner or lieen- <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 emp.10 r�any person in such manner <br /> as to become subject to Workman's Compensation laws of California:" <br /> / .�-� _ Owner <br /> Signed .(.tom ---------------------- <br /> __ ---- ------- Title -------------- ------------------ -------- ------------------------- <br /> ------------------------------- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> �} <br /> . -------- -- DATE <br /> APPLICATION ACCEPTED BY ------ -----#- t.-�-'-=--f- - <br /> ................................................... <br /> ----- --------- ----- - - -- .---- --------DATE ------- ---------------J�--------------•- <br /> -------- --------------- <br /> BUILDING PERMIT ISSUED ----------------- ----- --------------------------------------- <br /> ADDITIONALCOMMENTS . -------•----------------- -- ------- ------------------------------------------------------- <br /> - <br /> f /j <br /> ._-.. <br /> - -- __ - ••-_......__-•----------------------------------------------- <br /> - �• _ ------- <br /> --- <br /> _.._ <br /> -------------------------------------- w L� { ( !� it'd .-- ._. ......--- -----------..__..--------- <br /> D <br /> ---- � ------- ---. ate - -- <br /> Final Inspection - -- -- ------- <br /> - -------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E�H. 9 1-'68 Rev. 5M i _.... <br />