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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> Permit No. 77-2--T_3-7Ll <br /> (Complete in Triplicate) <br /> Date Issued <br /> - <br /> --------------------- ---------------------------------- <br /> ------------- _ This Permit Expires 1 Year From 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 with County Ordinance N 549 and existing Rules and Regulations: <br /> J ,Q r <br /> JOB ADDRESS/LOCA <br /> - ---""--- - -------- CENSUS TRACT <br /> Owner's Name :. -. ------ -------Phone ..-----------------••--------------- <br /> -------- --- ------------- <br /> Address f -�f 1. , <br /> --- ----- City <br /> ---------•------ <br /> Contractor's Name ---------- -------- __License # Phone -------------------- ......... <br /> will serve: Residence Apartment House❑ Commercial:❑Trailer Court i❑ <br /> t g <br /> Motel ❑Other -------------------------------------------- P <br /> Number of living units:-.-- ----- Number of bedrooms_-_-.Garbage Grinder ------------ Lot Size -------------------- ------ -------------- <br /> Water Supply: Public System andname ------------------------------ - - - Private [ ` <br /> Character of sail to a depth of 3 feet: Sand'❑ Silt Clay Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan 0 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 ----------------- ----- O <br /> Capacity -------------------- Type -------------------- Material---------------------- No. Compartments ----------------- .... . . <br /> Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ---------------------- <br /> LEACHING U = <br /> NE [ ] No. of Lines ------------------------. Length of eachline-=----------_---- ---------- Total Length ---------------------------- <br /> `D' Box ------------ Type Filter Material --------------Depth Filter Material -------------------------------•----------•- <br /> er <br /> Distance to nearest: Well ------------------------ Foundation -_ Pro_____---_---- --�- Property Line ------------------------ <br /> SEEPAGE PIT [ I Depth -------------------- Diameter ---------------- Number ------------------------- D__- Rock Filled Yes No C <br /> Water Table Depth --------------------------------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well -----------------------------------------Foundation.-----r--------------- Prop. Line --------..---------... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date -----------------------------------11 <br /> SepticTank (Specify Requirements) ------------------------------------- - --------------------—---------------- ----------------------------------------------------------- <br /> 4, <br /> ------ -------------------------------- <br /> Disposal Field (Specify Requirements) ---- ---- ---- <br /> t <br /> ---"y --------f---------------------------------------------------------------- <br /> --= <br /> 4 <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that 1 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, 1 shall not employ any person in such manner <br /> as to become subject to Workma s mpensation laws ZCaliifornia." <br /> Signed - -----'------------------------- -- ---- ------- --- - Owner - <br /> j�Title ............... <br /> — -- ---------------- <br /> BY / <br /> (If other than o } <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -----4 � . ------------- DATE -.-- ------------------7 <br /> ------- <br /> BUILDINGPERMIT ISSUED ------------------ ---------------------- ------------- ------------------------------------------------DATE ------------- ----------------------------- <br /> ADDITIONALCOMMENTS ---------------------------- -- ---------------------------------------- ----------------------------------------------------------- <br /> ' ------------------------------- -- ---------------------------------------------------------------------------------------------------------------- <br /> ---------------------- --------------------------- <br /> --------------------------- <br /> - `- -- -- --- ---- - -- - <br /> - tea- ----- <br /> - - Date��Final Inspection by: ____- --- <br /> ' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />