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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> _ =� - � Permit No: ------------------ <br /> ----- ----------- ------------- <br /> (Complete in Triplicate) <br /> ----------- <br /> Date Issued -�_-7 <br /> _ .�- <br /> This Permit Expires 1 Year From Date Issued 1 <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 /> JOB ADDRESS/LOCATION . 081 : ----------- -- -------- __ -- --------------- --------------CENSUS TRACT -------------------------- <br /> Owner's Name - ----------------------- -----------=--------- <br /> Phone <br /> , d - -.SSS ----- <br /> ----q -3-r-------- city -------------------------------------------- <br /> Address ------------ - �---j- � / I <br /> Contractor's Name . <br /> ............ <br /> - ------ . ----- License #l CJD 5�� Phone -- G.a <br /> Installation will serve: Residence)(Apartment House❑ Commercial : TrailerCourt ❑ " <br /> iMotel ❑ Other -------------------------------------------- <br /> Number of living units:____-.--(-'Nurr�ber of bedrooms ------,._Garbage Grinder _._-- ---- Lot Size .---__----- -------- Jr------- <br /> I 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 /> f (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 it permitted if public sewerris available within 200 feet,) <br /> ' F ✓yet S,; f. <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [T] Siie___-_______------------------------ Liquid Depth --------------------------VJ <br /> ` <br /> Capacity ` _ Type ------------------- -Material-------------'------ No. Compartments --------------------- <br /> P Y - , ti <br /> . t: Well -------------------------------------Foundation -------------------- '/Prop. Line --------------- <br /> Distancee to nearest: = <br /> LEACHING LINE [ ] No. of Lines -------- --------------- Length of each line------- _------- Total Length :__--_-----------------_--9 <br /> 'D' Box ------------ Type Filter Material --------------------Depth Filter Material --------------------------------------------Aro <br /> Distance to nearest:;Well-7�--------Foundation-_------------------------Property Line _---------------------- <br /> SEEPAGE PIT [ } Depth :--_-----______---- Diameter --------------1. Number ------------- ------- _- Rock Filled Yes ❑ No i❑ ro <br /> Water Table Depth ---------------------------------------------------Rock Size--- ---------------------- <br /> Distance to nearest: Well _ '".,[' -----------•---------Foundation __ ._:___�_________ Prop. Line ______________________ <br /> �.... <br /> REPAIR/ADDITION(Prev. Sanitation Permit ------ - v ----i r } ) <br /> ------------ ------------- - Date <br /> kJ <br /> Septic Tank (Specify Requirements) ------------- -+~ <br /> Z� Y . <br /> Disposal Field (Specify Requirements) ---- ----- ------------------ --------------- <br /> -------------------- <br /> k --- ------------------------ <br /> t--4 r_, <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'done4in accordance with San Joaquin <br /> County Ordinances, State Laws, and Rules,and Regulations of the San Joaquin Loc6114eatth 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;"{ shall'not`employ any'persan'in`suth manner <br /> as to become subject to Workman'sCorripensati.on laws of:California." <br /> Signed ----------------------------- ----- -� ----------------------- ------ Owner <br /> BY ---------- -- -- ------------------------- Title <br /> - ',------------------------------------------- <br /> (If oth tan owner) <br /> FOR DEPARTMENT USE ONLY <br /> ---------------- <br /> APPLICATION ACCEPTED BY -------- ---------- L -------------------------- ------- ---- DATE ---- <br /> BUIL NG PERMIT I SUED ----- --DATE------------------------------------------- <br /> �tC� <br /> A NTS � i--- ----- ------- ------- ------- -------- ----------------------------- - <br /> j -K <br /> ----------------------------------------------------------------------------------------------------- <br /> ---------------------------------------------- ------------------------------------------- <br /> ------------------------------ <br /> _ __ <br /> Final Inspection -- <br /> by: - : 0_(-�__ __ Date f �7 f <br /> V SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> G� <br /> E. H. 9 1-'68 Rev. 5M <br />