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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT Cy <br /> Permit No. <br /> --------- ----------------------------- <br /> (Complete in Triplicate) <br /> ----- --------------------------------------------------- <br /> ' Date IssuedThis Permit Expires 1 Year From Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a permit\to lh <br /> construct and instae-work-herein <br /> described. This application is made in compliance wit ounty Ordinance No. 5491 and existing Rules,-and Regulations <br /> TRACT --------------•----- <br /> JOB ADDRESS/LO- TiON—-n �-- _. -- ----------------------- CENSUS y.....-.�- <br /> Owner's Name -------------------------------------------------- <br /> I; `--------------Phone .-------------------------------011 <br /> ---- <br /> Owner's <br /> ------ <br /> one <br /> - - : <br /> Cary <br /> r. <br /> Contractor's Name _ ,License #�k _ o e <br /> } Y <br /> Installation will serve: Residence 0 partment House`[3 Commercial ❑Trdiler Court ❑ , <br /> ❑ <br /> Motel -Other --------- ----- --------- ---- - <br /> Number of living units:_-__r-____._ Number of bedrooms, Garbage Grinder ------------ Lot Size ---_ ---- ________ ---- <br /> ------------ <br /> Water Supply: Public System and name ------------`�------ ------------------------------------------------------ -----Private <br /> Character of soil to.a depth of 3 feet: Sand❑ ilt E] Clay .l] Peat❑ Sandy Loam ❑ Clay Laam,❑ <br /> f Wardpan. Ado ❑ ,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 /> k <br /> ;NEW INSTALLATION: (No septic tank or seep 6--Vit;permitted if' ublic sewer is available within 200 feet,} j C, <br /> i <br /> _w�f� <br /> SEPTIC TANK' Size? ---- '- _ Liquid Depth --�-------•----------- t <br /> J PACKAGE TREATMENT [ ] [ <br /> Capacity : Q� _ _-- Typ ---,�r-- -_ _� Ma r a` - No. Compartments --_- -.-•�-•--- <br /> istance to near t: Well ------V 0------------- <br /> -D ---- -- `•Foundati n ___:_--r--._------ Prop. Line --------•-.-.----•---- <br /> ? ` <br /> LEACHING LINE [ No. of Lin s ------- _-_------_-_Length of each line----- _____---_------- Total .Length ----- <br /> 'D' <br /> - - ------------ <br /> Ile <br /> 'D' Box --- -------- Type Filter Material ---- � ----Depth Filter Material -----n-------------------------------• <br /> Distance o neare3t: Wel! __ -------- <br /> 1&;-- Foundation a_ -� -_- Property Line ---- <br /> 1___ Rock Filled Yes No i❑ <br /> -SEEPAGE PIT [ Depth ---C�_S_---- Diameter __ ���--- Number --------�------- <br /> Ty <br /> _ --- .. <br /> Water Table Depth --------------7-U----------------- ---------Rock Size--/--- ------------- <br /> Distance to nearest: Well ------------Too--------}---------Found&ion���'��---_,------ Prop. Line ..._-�_-.----:---- <br /> REPAIR/ADDITION(Prev. Sanitation Permit.# -------------------------------------^ ._ Date-----------`--'-------�-------•- ) <br /> Septic Tank (Specify.Requirements) ---- -------------------------------------------------------------------- --' ---------. _--------- <br /> Disposal Field (Specify Requirements) ____-------- -----. <br /> -------- ------------ <br /> I _----------= <br /> �. '` --------------------------------------------------- <br /> ------ ------- <br /> --------------------- <br /> 11 = '- = <br /> (Draw existing and r <br /> equired 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 Reguhntions..of the. San Joaquin Local Health District. Home owner or licen- <br /> sed agents signature certifies the following: r <br /> "I certify that in the performance of the work for which-this,1-ermit is issued, I shall not employ any person in such manner <br /> ? as to become subject to kman's Compensation laws of California." <br /> --�..... ------ - caner.. <br /> ----------------------- <br /> By --------------------------- ------- --- -- -itle ---- ----- -- --------------------------------------------- <br /> (if other than owner) " J l f <br /> FOR rDEPARTM`ENT�USE-ONLY _ <br /> APPLICA-TION--ACCEPTED-BY- ---- ---- ----- -- -- --- DATE <br /> BUILDINGPERMIT ISSUED -- ------------------------- ------------------- ----------------------------------- --------------DATE ------------- ----------------------------- <br /> ADDITIONAL COMMENTS -------------------------------- --------------- <br /> - -------------------------------- ------------------------------------------------------ <br /> --------------------------------------------- ------ -- - -- --------=- ----- <br /> Final Inspection by --------- ------------------------- --------------------- -Date �"` � <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M. "' <br />