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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> ----------------------------- ----------------------- Permit No. __ - <br /> (Complete in Triplicate) <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/LOCATION � � '-- ------- Aa�---G --------- -- -------\-------------- CENSUS TRACT __ �------------ <br /> a� �a --------=- --------------- ---Phone ---------------------------------- <br /> Owner's Name <br /> - <br /> Address ------- -----=-------'------------------------------------------ City _..IE;54 ------------------------------------------------•--- <br /> Contractor's Name ---- e -----------------------------------------------------------------------License # ------------------------ Phone --------------------•--•---- <br /> Installation will serve. Residence E]Apartment House❑ Commercial :❑Trailer Court <br /> Motel ❑Other;�_reST_tttaM------;R-_ �-n____��� <br /> Number of living units_____________ Number of Bedroom ____--____Garbage Grinder ------------ tot Size ---__—VP ------------------------ <br /> Water Supply: Public System and name ----------------- ------------- --------�-------------�--------------------------�-------••- -------Priv❑ate,� <br /> Character of soil to a depth of 3 feet: Sand'❑ IS!&❑ Clay !Peat Sand Loam ClayLoam. <br /> Hardpan ❑ '"Adobe 'K Fill Material 1Y------------ If yes,type --_-____.___--------------- <br /> (Plot plan, showing size of lot, location of systerri in relation to wells, buildings, etc. must be placed on reverserside.)`` � <br /> NEW INSTALLATION: (No septic tank or seepage'- permittecl public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK:'[-,] "m Size---------I---------------------------------- -- Liquid Depth -------------------------- <br /> Capacity _���P_ Ty.p CCRs�C —Mat <br /> -_ � _ No. Compartments -19//_,,��,,,f N <br /> Distance to nearest: Well ___ ��_-` ___________.._______Fouti{{d��ation __._ ---------- Prop. Line o <br /> LEACHING LINE [ ] No. of Lines ----_--_t___________ __ Le g�taf reach line_______--1�-�___-___-__ Total Length - -___-.__-_______- <br /> 'D' Box . tiD--- Type Filter Material __ ]- ac Depth Filter Material _______ 11_____________________________ <br /> Distance to nearest: Well ----5-0__:{'------- Foundation ---_I�---------------- Property Line ---__-�________._._ . <br /> SEEPAGE PIT [ ] Depth ----a�_ --------- Diameter ----- Number ----------1---------------- Rock Filled Yes, No 0 <br /> Water Table Depth ----- S ---------------------------.--..Rock Size _(W4--w------------------ <br /> Distance to nearest: Well -----------------------------------------Foundation -------------------- Prop. Line -------- ------------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ------------ Date _______________________-__________) ;I <br /> Septic Tank (Specify Requir6ments) ---- ` = - - ---------------------------------------------------•----------------------------,----------------------------- <br /> Disposal Field (Specify Requirements) . ----.---- ---------------°--------------------------------------------- 4 <br /> r ----------------------- ti_ <br /> firs :+!'Y w <br /> - __________________________________._______--__.____ <br /> ------------------- -------------------------------------------------- ------------------------------------- --------------------------------------------------------------------------------------------- <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that I have prepared this application and that the wok 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: t ' <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 i <br /> as to become subject to Workman's Compensation laws of California." <br /> Signedr-- -- - - ------ ---------�----------—;---------------. Owner ' <br /> - ------ ----- ------ <br /> ----------- Title <br /> (If other than owner) <br /> FOR .DEPARTMENT USE, ONLY <br /> APPLICATION ACCEPTED BY ----- - ---------------------------------------•---------- <br /> ------------------------- - DATES ` � , <br /> BUILDING PERMIT ISSUED --------------------------------DATE -------------------------------- <br /> ADDITIONALCOMMENTS ---------------------------------------------------------------__------------- ---------------------------- --------------------- -------------------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> - _. <br /> ------------------------------- <br /> --------- <br /> i <br /> ------- ------------- <br /> ------------------------------ -- ----- d Final Inspection by: ----- - ---- ---------------.Date <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1.-'68 Rev. 5M <br />