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j FOR OFFICE USE: <br /> APPLICATION FOR SANITATION S172- <br /> ! <br /> ----- ----------- - - ; a- Permit No. _1 -/----- <br /> [ (Complete in Triplicate) F <br /> --....--"'------------------------------------------------ �,4 r7 <br /> --------------------------------------_--_--------- -- This Permit Expires 1 Year From Date Issued <br /> 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 No. 549 and existing Rules and Regulations: <br /> 1 - <br /> JOB ADDRESS/LOCATION ---------- ----�-----r--------------------------------" <br /> --------------------- ......--CENSUS TRACT <br /> RACT ----=-----�----.1-•----- <br /> Owner's Name - - - -----------Phone - <br /> _ <br /> __0X,_ -------COZ/ <br /> Address _474, City = „ <br /> Contractor's Name�---- --- --- ------------------------------License # ------------------------ Phone .-------------------- <br /> Installation will serve: Re idence ❑ Apartment House,❑ Commercial :❑Trailer Court ❑ <br /> Motel M'Other ------------------------------------------ <br /> Number <br /> -------------------------------=------Number of living units:......- Numbet of bedrooms ------------Garbage Grinder ------------ Lot Size ----------------------------------- <br /> Water Supply: Public System and name ------------------------------ - -------------------------------------------------------•------ Private ❑ <br /> Character.;of soil to a depth of 3 feet: Sand'❑ Silt I—) Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam:Rf <br /> Hardpan ❑ Adobe'❑ Fill Material ------------ If yes,type ............................ <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, e'tc. 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 -----------_---------._-.-- <br /> Capacity --------------------- Type -------------------- Material---------- ------------ No. Compartments ------•------- ....... rn <br /> Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line .._.._._....---..-_--- , <br /> LEACHING LINE [ j No. of Lines ��- ----- � ------------ Total Length ,_..._...- <br /> Length of each line ----- •-•--'-•--•• D <br /> 'D' Box . -- Type Filter Material ---Filter Material ___......................... . <br /> Distance to nearest: Well ._....--- -,. Foundation "1401...._..._-- Property Line.. ... <br /> -- Pro - -..--•--•-•-- �. <br /> Mo <br /> SEEPAGE PIT [ Depth --_�--------- Diameter .._._.. Number .- __. Rock Filled Yes No C <br /> WaterTable Depth ---------------------------------------=--------Rock Size -------------------------------- <br /> A ' <br /> Distance to nearest: Well - -.._...._.-_..._-.--------Foundation .------ ------------- Prop. Line ----------_.--..-.__.. <br /> /ADDITION(Prev. Sanitation Permit# ----------------------------------------------- Date ----------------------------------! <br /> Septic Tank (Specify Requirements) -----------------i------ ----------- ---------------0 - -----=------- ;t _ <br /> Disposal Field (Specify Requirements) _-� -.. "------------ ----------E- -.-- - -- <br /> , ., 1 Liu-- c- �, ------- <br /> . - - - -.-- - ---- .-I :---------------. <br /> (Draw existing and required.aaddition o 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 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 /> -------------- Title ---------.-------":. ------------------------------------------------------ <br /> ------------------------------ <br /> If other than owner),, <br /> FOR DEPARTMENT USE ONLY . <br /> APPLICATION ACCEPTED BY ------------ - '' --- -----. DATE <br /> - <br /> BUILDINGPERMIT ISSUED -------------------------------- -------------- -- `------------------------------DATE -=------------------------ ----------- <br /> ADDITIONALCOMMENTS --------------------------------------•--------------------------------------------------------------------------------------..•------------------------------- <br /> -------------------------------------------------------------------- -------------------------------------------------"------ -------------------------------------------------------- ----------•---- <br /> ----------------------------------------------------- --------------------- ----=------------------------------------------------------------------------------------------------------=-------------•-- <br /> ------- ---------- <br /> ------- --- -- -- <br /> Final Inspection by: --------��,�-�a' ------------------*=----- ---•------------------- ----------- Date ---::. .l ��f------------ <br /> SAN JOAQUIN ILOCAL HEALTH DISTRICT ,` c <br /> ~ E. H. 9 1-'68 Rev: 5M, <br /> - <br />