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FOR OFFICE USI:: I <br /> APPLICATION FOR SANITATION PERMIT <br /> --- -- ----- <br /> (Complete in Triplicated Permit No_ ________________� <br /> ------------------------------------------------ <br /> This Permit Expires 1 Year From Date Issued <br /> Date Issued _�t7._2_-�_Y <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 /> [� <br /> JOB ADDRESS <br /> . , CENSUS TRACT -------------=------- <br /> / TION _/ <br /> Owner's Name - ------ - -- - ------------------------- --------------------------------=-•----------- -------Phone ------------ ----------------------- <br /> 7 <br /> ------• - --••-•---- <br /> Address .- ---- a------ ��� �-----------. City `�z�� -V <br /> !Contractor's Name ----- - ----- -------f---------------i-�---- 't=�-�--'-------.License # -,1�V_,�____1-Phone ------ ----------------------- <br /> Installation will serve: Residence [Apartment House°❑ Commercial❑Trailer Court ,❑ <br /> Motel ❑Other ----------- <br /> ---- --f-- ----------------- ---- <br /> Number of living units:_____r__.__ Number of bedrooms _'IJ--___._Garbage Grinder ------------ Lot Size ---------------------_______.____________ <br /> Water Supply: Public System Kand name ----------------4-----------------•---------------- -------------------------------------------•---------------Private �.. <br /> Character of soil to a depth of 3 feet: S,and'❑ Silt ❑ Clay ❑ Peat❑ Sandy Loam [V Clay Loam ❑ <br /> Hardpan ❑ 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 ------- ------------------- <br /> Capacity -= TYPE-------------------- Material---------------------- No. Compartments <br /> Distance to nearest: Well ------------------------------------Foundation _.-------------------- Prop. Line .---------------------- <br /> LEACHING LINE [ ] No. of Lines Length of each line__.-______.________.____ Total Length -------------------_________ <br /> 'D' Box ------------ Type Filter Material _________________Depth Filter Material --------------------.___________..__...:..-. <br /> Distance to nearest: Well --------- ------------ Foundation ------------------------ Property Line -----_-____-__-___-_.___ <br /> SEEPAGE PIT [ ] Depth ____________________ Diameter ---------- Number -----------.---------------- Rock Filled Yes ❑ No <br /> Water Table Depth _ '-----------------------------------------Rock Size ------------ ----- <br /> Distance to nearest: Well _1_____________________________________Foundation -------------------- Prop. Line ---------------------- <br /> REPAIR/ADDITION(Prev..Sanitation-Permit# ----------- -- -----=------------= ------ Date ----------------------------------) <br /> Septic Tank (Specify Requirements) -------- ----------------------------- <br /> -------------------------------------------- -----------------------------.----------------------------- <br /> Disposal Field (Specify Requirements) ---------------------------------------------- -------------- -----------,---------------------------------- <br /> ------------------------------------ ° ------ ---- a__`�� ------- .. -_3 ----- <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 becom ubject to Workman's Compensation laws of California." <br /> Signed _.._._ Owner <br /> g _ -- <br /> Y Title _.. '2..`c-' _'{`' <br /> ---- ----------- ------ -- ----- ---- - --------- ----------------------- <br /> B - '� <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ---�- -tr --------------------------------------------------------- DATE - ------------- <br /> BUILDING PERMIT ISSUED --- --- -------------------- -- -------DATE --------------------------- <br /> - -- -- - - - - ------------------------- --------------- <br /> ADDITIONALCOMMENTS --------------------------------------------------------------------------------------------------------------------- ----------------------------------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ----------------------------------------------------------------------------------------------------------------------------- --- <br /> ---------------------------------- --------------------------------------- <br /> --------------- ----- --------- --- - - --------=`- 7.7---- -------------- <br /> Final Inspection by: ----- ,t ---------- ------Date - 1-0-f--------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'b$ Rev. 5M <br />