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FOR OFFICE USE: � y <br /> APPLICATION FOR SANITATION PERMIT ,T <br /> --------,-�>------------------------- ----------------- - -------� <br /> := * ICompleteinTriplicate) Permit No: <br /> ---------- ---------------------------------------------- <br /> ----------------------- -- <br /> -- ---------------------------- This Permit Expires 1 Year From Date Issued Date Issued --- --_---- <br /> v <br /> Application is hereby made to the San Joaquin Local Health District for a per to construct and install the work herein <br /> described. This application is made in compliance with Coun y Ordinance No. 349 and existing Rules and Regulations: <br /> /1 <br /> JOB ADDRESS/LOCATION .__.�� _____ �_________ _CENSUS TRACT _-_____.-____._---__----- <br /> Owner's Name --G __a ----`- t'P� i.�----- ---Phone ------ <br /> - d ........ I �--- City y ---------------------------------------- <br /> Address } <br /> Contractor's Name ---License* - 1-�=- _. Phone <br /> Installation will serve: Residence p rtment House❑ Commercial :❑Trailer Court ;[] <br /> Motel F-1 Other ------------------------------ ® � <br /> Number of living units:_./---- Number of bedrooms-_-_--Garbage Grinder ------------ Lot Size _ _____________________ <br /> Water Supply: Public System and name --_----__ � --------Private ❑ <br /> - ---------------------- <br /> Character of soil to a depth of 3 feet: Sand'[] Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam <br /> Hardpan E-] Adobe Fill Material ------------ If yes, type -----------------------_--- <br /> E <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/p"ublic sewer is available within 200 feet,) r <br /> PACKAGE,TREATM'ENT { ] SEPTI <br /> Size--rT �d`x _ Liquid Depth' <br /> _ <br /> -- - -------- --------------- <br /> Capacit .'r _% pe" _ Material_� `�_.. No. Compartments ____ .-_-----_-- <br /> JDistance ,to nearest: Well _._ AXsf�--'_-___--.--Foundation __, __.___.___- Prop. Line _— _�. ���! <br /> p j , - <br /> LEACHING LINE `' No. of Lines ---- �__-___.___ Length of each line_ 5 _D*�_-------- Total Length ---/2"e. <br /> 'D Box ----/---- Type Filter Material!_ *Depth Filter Material ----- <br /> fr ------------- <br /> SEEPAGE <br /> --------- - <br /> Distance to nearest: Wel! _��- Foundation- __ ------__-_-- Property Line :�._-..� <br /> 1 <br /> SEEPAGE PIT X Depth . ----- Diameter _ 2_ ------ <br /> Number .-------.v-------------r.r__ Rock Filled Yes )J. No <br /> Water Table Depth------.c��---------------- ------ Rock Size fid -:- --------------- <br /> D <br /> -.-----_--- r ` <br /> Distance to nearest: Well _- --------------Foundation _ ____.___ Prop. Line --�._..__ .. <br /> REPAIR/ADDITION(Prev. Sanitation Permit# :-----.- ------------------ ------------ Date ---------------------------------_) <br /> SepticTank (Specify Requirements) --------------------------------- -----------------------------------•------------ ------------------------------ ---------------------------- <br /> DisposalField (Specify Requirements), ------------------------------------------.-------------------- ----------------------------------------------------------------------- <br /> -------------------------------------------------------- i . <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 tlie'•San^Joaquin Local Health District. Home owner or licen- <br /> sed agents signature certifies the following: _ i ,_- <br /> "I certify that in the performance of the work for which this permit is issued,31 shall not employ any person in such manner <br /> as to be e s t to ikm 's Compens o laws of California." <br /> i <br /> Signed - --- ----- -- -- - - ----- ----- <br /> ------- Owner <br /> y ------ r. � - ------ --= = Title --------- ------------- -------------------------------------------- ' <br /> {If other th n owner <br /> f FOR DEPARTMENT USE ONLY! <br /> i <br /> APPLICATION ACCEPTED BY -------- _ ----__ DATE <br /> --------------------------------------------- - -------- <br /> BUILDING PERMIT ISSUED ------'---------------------------- ---- = ----------- --DATE -- --•- --------- - -------- +. <br /> ADDITIONAL COMMENTS ------�-- =- `- _ . � --,� • <br /> ---------- <br /> _ ---------- -�__fir P ------------ - ------ <br /> + ' <br /> - by--------- _ / `. - ---� / 1D-=: � ------�.A` <br /> . . - Date <br /> Final Inspection► by: ----------------- ----------- ------ ��------- ,¢ /_._.2rr'. ----------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br /> } 1 <br />