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r FOR OFFICE USE: <br /> L, APPLICATION FOR SANITATION PERMIT '7"71 <br /> is y <br /> r ------ ---- / --------------------- (Complete in Triplicate) Permit No. -..- ---------- <br /> ----------------------------------------------- 7 7{C <br /> - ------•--- <br /> 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 /> JOB ADDRESS/LO ATION ---------------------- --------------- ------CENSUS TRACT ----------------76--- <br /> ` l ., - Phone. =- 7�. <br /> Owner's Nam d_ - � �� <br /> 1 - <br /> { Address �(�-� r�� � City - 'L ---- --------------------------- <br /> ------------------- <br /> t Contractor's Name -- -- f" -U` •----------------------------------------License # /- Phone - ll- ---------------- <br /> Installation <br /> _-------"_--Installation will serve: Residence Apartment House❑ Commercial:❑Trailer Court i❑ <br /> Motel ❑ Other ------------------------------------------ <br /> Number of living units:---- ----- Number of bedrooms ---- - ----Garbage Grinder ------------ Lot Size --------------- - <br /> �( Water Supply: Public System and name ------------------------------------------------------------------------------------------------------•-------Private \' <br /> Character of soil to a depth of 3 feet: Sand�ff Silt❑ Clay ❑ Peat ❑ Sandy Loam •❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe 'D Fill Material ------------ If yes,type ----------------_------.--- �� <br /> (PI'ot 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'[ ] Size------ ------------------- ----------- ---- Liquid Depth ----___--_------_------- <br /> Capacity -------------------- Type -------------------- oterial---- ----------------- No. Compartments ------•--------.-•---- <br /> r Distance to nearest: Well ----------------- ----_-__----_-_-. oundation ---..----------------- Prop. Line _-----_------------.- <br /> ' LEACHING LINE [ ] No. of Lines ---------------__----.- Lengt of each !i e-_---------___---.--- Total Length k ...-------•--_. <br /> 'D' Box ------------ Type Filter Mate al --_--------- ------Depth Filter Material -------------------- -------------------- <br /> e <br /> Distance to nearest: Well ------- --------------- F ndation ------------------------ Property Line -------------- ._-•_-- <br /> SEEPAGE PIT [ ] Depth -------------------- Diame r ----____-----_ u ber __-_.-------.--------------- Rock Filled Yes ❑ No i❑ <br /> Water Table Depth --------- ---- --------------- ---------------Rock Size ---------------------.---------- <br /> Distance to nearest: Well <br /> c/ t <br /> --------------------- Prop. Line ..-.---_--.._..------- <br /> REPAIRfADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----_---T---.-.------------------ <br /> ) <br /> SepticTank (Specify Requirements) ----- -- ---------------------------------------------------------------------- ------------------------- - ------�-------------------- <br /> ments) � �` �'%FDisposal Field (Speccf r - { ---------------- <br /> __,_1__7_ - - ---------------------- <br /> -------------------------------------- ---- ---------------------------------------------------•-------------------------------------------------------------------------------------------- <br /> (Draw existing and required addition on reverse side) <br /> 1 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. Homeowner 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 /> SignedOwner <br /> --- - -- -- --- <br /> By ------ = Title <br /> (If other than owner <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ----------------------------------------------- DATE -L-------------y-------- ---------• <br /> BUILDINGPERMIT ISSUED ------------------------------------------------------------------------ ----------------------------- ---DATE ------------- ------------------------••--- <br /> ADDITIONALCOMMENTS ------------------ ------------------------------------------------------------------------------------------------ -------------------- ---------------------- <br /> ----------------------------------------------------------------------------------------------------- ---------------------------- ----------------------------------------------------------------------- <br /> -- -------- -------------------------------------------------------------------------------------=----•- <br /> ------- --- <br /> Final Inspection by: --- -- <br /> Date <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />