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n <br /> nQR�OFICE USE: APPLICATION FOR SANITATION PERMIT �. + <br /> - -- ------------------ ------ Permit No, --7---------/------ <br /> (Complete in Triplicate) <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. Al's.application is made in complianwith Count rdinance No. 549 and existing Rules and Regulations: <br /> ADDRESS <br /> ' /{OCATION _ ENSUS TRACT <br /> JOB <br /> J_ . r <br /> Owners Name �� f . fi ----- �a A------------Phone ----------------------- <br /> AddressCity 1,.� ( '� <br /> Contractor's Name_'_X <br /> 7 ' License # : `., Phone ------------------------------ <br /> Installation will serve:".. Residence ❑ Apartment House❑ Commercial :[Frailer CourtlE;❑ <br /> 6' <br /> ' y Motel ❑ Other -------------------------------------------- <br /> e'r-'-of living units:--------- Number of bedrooms " -----Garbage Grinder ----- ... Lot Size'/ ----------------_-- <br /> W erSupply:Public-System-and'name. �"' --------------------•--------------------------------------- -----------------Private <br /> Characte of foil-to'a depth,of 3 feet: Sand;'(] Silt❑ Clay []Peat❑ Sandy Loam ❑ ;Clay Loam ❑ <br /> Hardpan ❑ Adobe Fill Material ------------ If yes, type ------ -------------------- <br /> (Plot <br /> --------------- --(Plot plan, showing size of lot, location of system in relation to wells,;buildings, etc. must beplaced on reverse side.) <br /> NEW INSTALLATION: (No septic flank or saepage pit permitted if public sewer is available within 200 feet,) <br /> fPACKAGE TREATMENT { ] SEPTIC TANK j .] Size---------------#---------------------- Liquid Depth ___.__-.-_________,_---- I <br /> Capacity ----------------------- Type -----------------r Material---------------------- No. Compartments ---------------- -.._ i <br /> Distance.ft6 nearest: Well ------------------Y-------- _-.----Foundation ---------------------- Prop.,Line ------_--------------- <br /> LEACHING LINE [ ] 'k No l of Lines t'------__-_'_---_.._____ Length of ?6dch line______ _____________________ Total Length ---------------------------- <br /> 1 <br /> D 'Box:_-�_--_._ Type Filter Material ------- ----------- Filter Material __ f'_________________________ <br /> Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line-- --------------------- <br /> ' <br /> SEEPAGE PIT Depth' --------- ---------- Diameter _______________ Number ___---------.-_.__________ RocklFilled '_Ye No i0 <br /> [ p { <br />' Water Table Depth ----------------------------------------------=-Rock Size ---------------------- '------- <br /> Distance`ia <br /> ------ <br /> Distance'to nearest: Well _____________________ ____------Foundation -------------------- Prop. Line ---___________-_.-__-. <br /> s <br /> REPAIRJADDITION(Prev. Sanitation Pefmit# -------------------------------------------- date -------------------------------- <br /> Septic <br /> __-- --_--------------------__-<-} r�� <br /> r Septic Tank (Specify Requirements) --------------- <br /> -S -------------- <br /> ---------------- <br /> Disposal <br /> ----------- ... <br />{ Disposal Field (S <br /> pecify Requirements) _- _ _ __ ______ <br /> -- ------ <br /> . F (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,Sa`n 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 /> "1 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 Ce ifornia." <br /> F <br /> 5igned -------- -.---------- Owner <br /> ,�„ r <br /> By -------------------- �(l� -----`----------------------- Fr?-------- Title y <br /> (If r than owner) r <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION. ACCEPTED BY .-4�� -------=----------1---- F --------------------------------------------- DATE /2`Z ----------------- <br /> BUILDING PERMIT ISSUED -------------------------------------------------- --------------------------------DATE ------------------- <br /> ------------------- ---------------------- <br /> r ADDITIONAL COMMENTS ----------------------_------ - W-- <br /> ----------------------- -------------- - ---------- ------ ---------------------------------------------------------------- <br /> 4. <br /> E -�------------------------------------------ -------y---------------------------t �------- ---------t--- <br /> ---------------------------------- -------------------------- <br /> ----------------------------- <br /> ----------------•- <br /> - -- ------------- � - ---------------- - ---------- =---- �final Inspection -T -------Date ---------------------------- <br /> ----------------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> M <br /> E. H. 9 1-'6B Rev. 5M <br />