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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> ----------- ------------------- --- ------------- <br /> � (Complete in Triplicate) Permit No. <br /> -------------------------------------------------------- <br /> Date Issued <br /> -------------------- This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to the San Joaquin Local Health Pis ict for a permit to construct and install the work herein <br /> described. This appli ation is,;gna "cph e v%4, � inance�No. 549 and existing Rules and Regulations. <br /> JOB ADDRESS/ CA ION - �- �____-- �.__ l_. __ _f&�rr c --- � --- t !�� _&N,A5STCT -------------------------- <br /> Owner's Name ---- -/A- ---- ------------ ------Phone ----------------------------- <br /> Address � r_L �"�p -.-------------------------------- City -AV- -------------------- <br /> Contractor's Name __,41"1 _--------"------ ----A -----------.L' --------------------- <br /> Installation will serve: Residence ['J Apartment House❑ Comr,06rcial ❑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'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam,] <br /> Hardpan [t] 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'[ ] Size---------- ------------------------------------- Liquid Depth -----------------------.-- c� <br /> Capacity -------------------- Type --------------- ---- Material-------- --- -----..-- No. Compartments ------------ ......... <br /> Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line --------------------.- <br /> LEACHING 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 13 <br /> WaterTable Depth ------------------------------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well ________________________________________Foundation -------------------- Prop. Line ____--_.._.___________ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) <br /> SepticTank (Specify Requirements) --------------------------------------------------------------------- --------------------------<---------------------------- <br /> Disposal Field (Specify Requirements) _______.��- - --'-____-- <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 .� g 4 '/Compensation laws of California." <br /> Signed ecame-su a P(. "{/rkm Owner <br /> By -------------- -------------------------------------------------------------------- ----------------- Title - ---- --------------------- <br /> (If other than owner[ <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -- ' - ------------------------------- ------------------------- DATE9_76_(�.7---------------------------- <br /> -----------PERMIT ISSUED --- ----------- ---- ----------------------- <br /> ---- -� DATE <br /> ADDITIONAL COMMENTS _.. r.- = -- --- -------- --"'--- --- 10--- <br /> -------------------------------------------------------- <br /> -..- <br /> -------------------- - -------- --------- ----------------- <br /> ------------------------------------------------ ----- - --------------------------------- <br /> ------------------------------------- -- ---- -------- .� <br /> Final Inspection by: --------------------------------------------------------------Date ---- - c <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />