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FOR OFFICE USE: <br /> 3 APPLICATION FOR SANITATION PERMIT <br /> Permit No. 71__.3 '�___.. <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. This application is made in compliance ith County Ordinance No. 549 and. existing Rules and Regulations: <br /> JOB ADDRESS/LOC�A_TIIOON�. ------ -- ----------------------------------------------CENSUS TRACT -------------------------- <br /> Owner's Name -/�/ 1y 1r�J--------------------- Phone � _ r . <br /> Address '----------------------- <br /> -- =------------------------------------------------- city <br /> Contractor's Name --------------------License # Phone <br /> Installation will serve:---- --.Residence Apartment House,❑.Commercial•.:❑Trailer-Court-❑-- - <br /> Motel ❑Other -------------------------------------------- <br /> Number of living units:----.----- Numlaer of laedrooms'.-_'T-----Garbage.Grinder TLotSize __--._ <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 ❑ Adobe [) Fill Material----------- If yes, type _-_L---------------------- <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 ---_--------------------:- b(1 <br /> Capacity ------ Type -F----------------- Material------------------------. No. Compartments ------ -----.....: r <br /> Distance to nearest: Well ____________________________________Foundation ____-_______-:_-_--__` Prop. Line ---------------_-_---_ <br /> LEACHING LINE [ j No. of Lines ------------------------ Length of each line____________________________ Total Length ----------------------------- <br /> 'D' <br /> -_-..-______ _--__'D' Box ------------ Type Filter Material --------------------Depth Filter Material --------------------------------------------- <br /> Distance to nearest: Well ------------------------ Foundation ------------------------ Property Lime _--_----_-.:._..-_._..__ <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No i❑ <br /> Water Table Depth ------_----_ 77 # <br /> -----------------7---------•_------Rock Size - --- -- -- •-- <br /> Distance to nearest: Well -----------------------'_------_)_-_--_Foundation <br /> - -------------------- Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# --------------------------------------------- Date ____ ------------------------------ <br /> Septic <br /> __-_--------___---- _-_----Septic Tank (Specify Requirements) --------------------------------------------------------------------------------------------------------------,,.---------- <br /> Dis o/al Field fSpecify Requirements) -- - _Xl-r ----c --- - -- --------:_- _ ------------e�_;------------------ <br /> -- ------------------------------------------ <br /> T <br /> ----------------------------------------------- --------i----- ------------------ <br /> -- - ------------------------------------------------------------- -------------------------------------------------------------------- <br /> (Draw existing drid.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 Districi. 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 become subject to Workman's Compensation laws of California." r <br /> caner---•---- <br /> BY \� ------ Title ------- <br /> {If other than owner} i <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY--- -------------------------------- -- <---------------------------------------.-. DATE ------------ <br /> BUILDING PERMIT ISSUED ------------- --------------------------DATE - - - ------------------------------------ <br /> ADDITIONALCOMMENTS ------------------------ ------------------------------------------------------------------------------------------------------------------------------------- <br /> .,ry <br /> -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ------------------------------------------------------------- <br /> - --------------------------------------- ----------------------------------------------------------------- --- <br /> ---------------------------------------------- <br /> ------- <br /> - - - - - ------------------------------------------------------------------ ---------- <br /> Final Inspection b <br /> >' Y- - --- ----- ----- Date 2 _ <br /> ---------- ------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br /> �'' 1 <br />