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FOR 6FFICE USE: APPLICATION FOR SANITATION PERMIT r` <br /> "= Permit No: <br /> (Complete in Triplicate} -�--------- <br /> 7AN-_--------------- <br /> S � 7S� <br /> This Permit Expires 1 Year From Date Issued Date issued !_ __ _____ <br /> - ---------- <br /> Application is hereby made to the San Joaquin Local Health District for a per 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/LOCAkT[QNa-tdIJP1,4XD&4dw _ ' <br /> CENSUS TRACT <br /> --- ---- <br /> Owner's Name �J _ ---------------------------------- ----- ------Phone -�7 _7G� --•-•- <br /> -------- - - <br /> Address -------------------f 3oC� _-Q^-�re City fc ------------- - <br /> Contractor's Name ------------- -- :--- -- '` -----------------------------License # .�-7-: � ---- Phone _`-- —-- 6 ------- <br /> Installation will serve: ResidenceX Apartment House❑ Commercial ;❑Trailer Court ',❑ <br /> Motel ❑ Other -------------------------------------------- ? <br /> Number of living units:_________ Number of bedrooms ___3_____Garbage Grinder _ Lot Size _.��--- /----------•-.•.. <br /> Water Supply: Public System and name __________________________________ <br /> -----------------------------��---C1------ --------------------------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 /> (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 /> r ( 'r <br /> PACKAGE TREATMENT [ ] SEPTIC TANK' Size-___._-�---� ----------------------- Liquid Depth __ ..._.._ _____ <br /> T '___ No. Compartments -- <br /> Capaaty 1 Type ------- -- Material �-lf - <br /> -. 1$ <br /> Distance to nearest: Well ------------------------------------Foundation---------------------- Prop. Line ----------­-------- <br /> LEACHING <br /> ---------­--------LEACHING LINE No. of Lines ----- Length of each line._.__.-5�_Q------------- Total Length ____AY)-.__________---e� <br /> D' Box _ __ Type Filter Material 4" Depth Filter Material --------lR_r---------------- <br /> _.......... <br /> Distance to nearest: Well ________________________ Foundation ----l0_f__t._--_. Property Line __. -r___....____.___ <br /> r r� <br /> SEEPAGE PIT �, Depth ___} __.__ ___ Diameter __` _:_____ Number ---------`>�___ _..__ RockFilledFilled Yes [� No C! <br /> Water Table Depth / trt� f-tl- r r <br /> p ------------------------ ---Rock Size *---- �'---- <br /> Distance to nearest: Well ________________________________________Foundation ___/0_'t_____ Prop. Line - ........ <br /> REPAIR/ADDITION(Prev, Sanitation Permit# _________________ <br /> - ------------------------- Date ----------------------------------) <br /> SepticTank (Specify Requirements) ------------------------------------------------------------ ---------------------------------------------------..-----------------------_-- <br /> Disposal <br /> ----- -------------- -- <br /> Disposal Field (Specify Requirements) --------------•--•------------------------------------------ ------------------------------------------- --------------- <br /> ------------------- ----- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ <br /> -------------- ------- ------------------- <br /> ----- ---------------------------------------------- - ---------------------------- - -- ------------------------------------------------------------------------------------------------------ <br /> (Draw existing and required addition on reverse 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 licen- <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 employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed -------------------------- -- --------- ------- - ------------------------------------- Owner <br /> ` . <br /> BY ;L/L.1------ ------ Title <br /> - - ----------------------- --------------------------------------- <br /> (If othe an owner) c� <br /> FO DEP TMENT USE ONLY i. <br /> APPLICATION ACCEPTED BY ------. _ DATE _; ----- -�-- - --------- <br /> BUILDING PERMIT ISSUED --__-_-- DATE -------- <br /> ---------- -- - <br /> ADDITIONAL COMMENTS --tea --- --- <br /> -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•-- <br /> Final Inspection by a -1: -` ,-- -----------Date =--- - - /- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> N <br /> E. H. 9 1-'68 Rev. 5M <br />