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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT rI <br /> -------- - -- - -------- --------- ----- _ Permit No. ._�-� <br /> _ y (Complete in Triplicate) <br /> "- <br /> ---------- ------ - ' ----------- <br /> '1 <br /> ______________________ _---____ i'� This Permit Expires 1 Year From Date Issued Date-Issued <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 Regulations. <br /> �� `1 S`�7 <br /> JOB ADDRESS/LOCATION _l -1� -.CG- �L ----" --------=--=---------------------CENSUS TRACT -------------------------- <br /> Owner's <br /> --- --------- <br /> Owner's Name ------1-:_2 <br /> ' -------------Phone --------------- --• <br /> - - <br /> ---------------------------------------------- <br /> Address ' %�� r = f <br /> ty <br /> . - 't <br /> I r ---------------------------------------------------------- - -----•-• <br /> Contractor's Name -� - - ----- °-------License / <br /> # /�.Y3�z---- Phone .............................. <br /> Installation will serve: Residence Apartment House❑ Commercial : Trailer Court ',❑ <br /> Motel ❑Other <br /> Number of living units: Number of bedrooms -- -_--_Garbage Grinder -----------. Lot Size -------------------------------------------- <br /> Water Supply: Public System and name --------------------------------------=------------------------------------------------------------•---------.Private it <br /> Character of soil to a depth;of 3 feet: Sand'Ej Silt❑ Clay ❑ Peat❑ Sandy Loam •❑ Clay Loam ❑ <br /> r Hardpan ( Adobe ❑ Fill Material ------------ 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 /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK f] Size------------------------------------------------ Liquid Depth -----------..-- _ ------- � <br /> V <br /> Capacity ---------- ----- --- Type ---------- -------- Material---------- --------- No. Compartments ----------------------- <br /> Distance <br /> ---- --- <br /> Distance to nearest: Well ---------- -------------------- <br /> -_-Foundation ---------------------- Prop. Line --------- ............ -.0LEACHING LINE [ ] No. of Lines ------------------------ Length of each line------------------- ------ Total Length ,.--__----_.--_.--.-----_-__ <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 ❑ No 0 <br /> ' Water Table,Depth -- -------------------------- --------Rock Size --------------------------_- <br /> Distance <br /> --------------• - _-Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ...................... <br /> REPAIR/ADDITION(Prey. Sanitation'Permit# -..-----.--- ------------------------- Date ----------------------------------) <br /> Septic Tank (Specify Requirements) -------- ------- ---------------------------•----------------------------- <br /> Disposal;Field (Specify Requirements) ------------- -- - - ----- - �`-���----- .-.---_----------- <br /> �'` <br /> :. <br /> - <br /> r - - <br /> --- --------------•------- <br /> ` (Draw existing and required addition on reverse side) <br /> i 1 hereby Icertify 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 licen- <br /> sed agents signature certifies the following: <br /> "1 certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner <br /> as to become'subject to Workman's Compensation laws�of California." <br /> Signed ----------1--------- ------------------------ t�- -�.- ----_----- ------ Owner <br /> By ------ ----------=------------------------------- - -- -� V` `f` Title -... ,C s: c-- uu - <br /> (If other than owner) <br /> } FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY - = -------•---------------------------------- DATE ---- .2— <br /> BUILDING PERMIT ISSUED ___--- -------------------------------------------DATE .------- <br /> ADDITIONALCOMMENTS ------------------------------------------------------ -------•---------------------------------------------------------------- ---=-------- -------------- <br /> ---------- ----------- ------------------------------------------------------------------------- <br /> -----------------------------------=----------------------------------------------------------------------------------------------------------------------------------------------------------Z------ <br /> ------------------ <br /> ----------------- -- ----------- <br /> ---------------------- <br /> ------- ------------------------ -------=--------------------------------------------------------------------------------- -- - <br /> - --------------- --------- ----- ------------ <br /> - <br /> d <br /> ----- -- ------ -- <br /> ----- o ----------------- --Date----------- <br /> Final Ins ecfiion by: r <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />