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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT 1 _—_&_q-77l <br /> Permit No. - -- - -- ---------- <br /> - (Complete in Triplicate) <br /> -------- ---------� --------- --------- --------- ----- Date Issued -------------- ---- <br /> This Permit Expires 1 Year From Date Issued <br /> ----------------------------------------------------- <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 /> J � _ 4 <br /> - -- -----------CENSUS TRACT -------------------------- <br /> JOB ADDRESS/LOCATION .---.I��-_ _� - �-- -- - - - - <br /> Phone ------------------------------------ <br /> ----------------------------- <br /> Owner's Name ---------------------- <br /> — <br /> Address ---IAAOO.. i Phone ------------------------------ <br /> ------- <br /> City --- - ----------------------- <br /> Contractor's Name - --------- ---- ..License # -- � - <br /> Installation will serve: Residence Apartment House°❑ Commerci I ❑Trailer Court <br /> II Motel ❑ Other ------------- ---- - <br /> [ Number of living units:-----'- Number of bedrooms --_.________Garbage Grinder _._._-_.---_ Lot Size ___________._______._ <br /> ------- ---------�Private �. <br /> Water Supply: Public System an name ---------------- ------------------- ------- ---- - <br /> -------------------------------------- <br /> [ Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam <br /> + Hardpan ❑ Adobe ❑ Fill Materia! ------------ 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 /> " sept <br /> tank seeps a pit permitted if public sewer is available within 200 feet,) <br /> NEW INSTALLATION: (No se or <br /> SEPTIC TANK' Size ---- ----- Liquid Depth -------------------- <br /> PACKAGE <br /> - 6� <br /> PACKAGE TREATMENT [ ] [ � � � <br /> Capacity -- -- -- Type(��', '--- Material-- -8�_---- No. Compartments _._�-t---••--•••- ` <br /> istance to ne est: Well _---______. p_ ---------------Foundation ------- ------- Prop. Line ...:`�---r----------- <br /> e / <br /> LEACHING LINE [ <br /> No. of Lines j ------------ Length of each line------- ---------- -- Total Length ��•----• <br /> — ---------------- <br /> Distance <br /> ----------- -- <br /> - T e"Filter Material _-____�.��__-Depth Filter Material _.______._J -_____- -__S <br /> r 'D` Boz:'�-_. _ YP <br /> Distance to nearest: Well __�----�0!-`---- Foundation ----------'�-�-------- Property Line --------------------­--- <br /> Diameter <br /> -------• ----•--- <br /> 1 ____ Number --- Rock Filled Yes ❑ No 0 <br /> SEEPAGE PIT [ ] Depth Diameter -_-- --_-- <br /> { Water Table Depth ------- ------------------------- <br /> Distance <br /> Size -------------------------- <br /> t <br /> 4 Distahce to nearest.. Well -------'------------------------------- Foundation ---------------•---. Prop. Line _._._.......--_-..•- <br /> • a i ----- <br /> } <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date = <br /> 5 <br /> ____ __ __________ ________________________________________________________:__._._______...-------------------------- <br /> Septic <br /> _____.______--____-_____.5eptic Tank (Specify Requirements) -----------________-- - - - -. <br /> Disposal ( ~------------- <br /> Field (Specify Requirements} _____________ _ <br /> - <br /> i. { ---------------------------------->-________-.-_________-__ <br /> __________ ______________,___.--______i_---.._______----___________.____________________ _----_________----__-______-- <br /> ` x _____ _ ___________ __________________ <br /> __ ________ ________________ ___ _ _ ____�__.___-______ -__.._____..._____.___________________-__.____. <br /> _____ ___ _____________ <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 become subject to Workman's Compensation laws of California." <br /> Signed ------- ------{--- ----- ----------------- ------ Owner <br /> - - --- ---------- ---- <br /> o:J Yitle <br /> [if other than owner) <br /> F FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -------------------------------------- -------------- <br /> ------- DATE -`7--Jf.r-•7 --•------ --------- - <br /> ----------------------- - <br /> BUILDING PERMIT ISSUED ------- ---------- <br /> ----- D ------------- ----------- ----------- ----- <br /> ADDITIONAL COMMENTS _._ <br /> ------------------------------------------------------------------------------------------------------------------------ - -:, - <br /> ---------------------------------------- <br /> - <br /> �,. Final Inspection by: ! _ ---------- Date <br /> i SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> k E. H. 9 ..1-'68 Rev. 5M_ . <br />