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FOR OFFICE USE: <br /> ---------- --- ------ --- APPLICATION FOR SANITATION PERMIT <br /> =------- ��--��-''�------ � Permit No: _7�_'-av7 ; <br /> (Complete in Triplicate) <br /> ---------------------------------------------------------- <br /> This Permit Expires 1 Year From Date Issued Date Issued - ___�z -�3 <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 made in compliance with County Ordinance No- 549 and existing Rules and Regulatibns: . <br /> f f - <br /> JOB ADDRESS/LOCATION ._._ t - ,1 /"L '1 ----.CENSUS TRACT -------------- --•--•----- <br /> y,.� <br /> Owner's Namey���_5 - �'�`�� --------------- ------------------ Phone <br /> _ <br /> ----------------------------•-.----- <br /> - ---_.Address - Ci+Y ------------------------------ --- <br /> 2dlrl,w' <br /> Contractor's Name ..... _- -.if :- --- 49A1-10" -----------------•- -------License #g f,s _ _ Phone 4X� T_ <br /> Installation will serve: Residence IrApartment House-[] Commercial:❑Trailer Court ',❑ <br /> Motel ❑ Other <br /> Number of living units:--- Number of bedrooms Garbage Grinder ._ Lot Size .19 <br /> Water Supply: Public System and name ---------------------------------------------------------------------------------------------------------------Private �$ <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑,' Peat❑ Sandy Loam ❑ Clay Loam <br /> { Hardpan ❑ Adobe ❑ Fill Material ------------ If Yes, type __________________________ <br /> 4 <br /> (Plot plan, showing size of lot, location of system in relation to weLls,lbuildings, 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 /> PACKAGE TREATMENT ! <br /> [ j SEP TiIC TANK Size_ _ _' - ------------------- Liquid Depth ---------•---_ -- <br /> Ir <br /> Capacity _ ______ Type�/f� Material� ,t _�.__ No. Compartments ___�--_- r <br /> t ® <br /> Distance to nearest: Well /` <br /> Foundation __ __ ___ <br /> --�--------------- - ------------ Prop. Line �-..:.....--- <br /> LEACHING LINE No. of Lines ------ -------------- Length of or line... Total Length _Td.0.-----_____...-. <br /> D' Box /IW. - -- Type Filter Material/_ Depth Filter Material �� � { <br /> Distance to nearest: Well ----;11P-/------ Foundation ._1�---._.___,__ Property Line k'`_ _____________ <br /> SEEPAGE PIT [ ] Depth -__________________ Diameter ---------------- Number ---------_.----------------- Rock Filled Yes ❑ No i❑ <br /> *# w 11' <br /> Water Table Depth -------------------�. .�--_-Rock-Size = = - ==------ I <br /> le <br /> Distance to•nearest: Well -----------------------------------------Foundation ---------------------,Prop. Line --------.------.-.---_ <br /> REPAIR/ADDITION{Prov. Sanitation Permit.# --------- Date ______________________________) 'fir <br /> Septic Tank {Specify tRe_rqu6iarement �° - - -- i _ <br /> ___.s) - ----- <br /> -•----'----- <br /> Dis osal Field IS &cifY -Requirements) --_____ -• ---- 1 - ------- ------- -- <br /> ti �' -_----------------------------- <br /> ____________________________________________*_-qr_---__.__.__----__-_i _--.--______._-_--__-__-__--___ _______.-__------______.--_-_-_-________-------_____._------_________-----_----______._--_-. <br /> -(Draw.existing-and.required addition-on_reverse <br /> 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 Iicen- <br /> sed'agents signature certifies the following: I <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 become subject to Workman's Compensation-laws_of California." <br /> F <br /> Signed - '✓ W--------- ,.• r <br /> ----IBY --- Title /" <br /> (If other n owner} <br /> EPAitTMENT USE ONLY <br /> APPLICATION ACCEPTED BY - ----- -- -- - ---- --------------------------------------------------------- . DATE - 17 t <br /> BUILDING PERMIT ISSUED ------ p --- --- - --------------------------------------------------------------DATE ------------------------------------------ <br /> ADDITIONAL COMMENTS - _ <br /> --------------------------------------------------------------- ---------------------------------------•----•--------------••---- <br /> -------------------------------------------- <br /> ------ ----- --- -------------------------- - <br /> -------------------------------------- ------------------------------------------------------------------------------------------ <br /> Final inspection by: -------- ----------- ---- ---------------------------------------Date h' =1G <br /> Al JOAQUIN LOCAL HEALTH DISTRICT I <br /> I <br /> E. H. 9 1-'6$ Re <br />