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FOR OFFICE USE: <br /> - APPLICATION FOR SANITATION PERMIT <br /> Permit No. _ '_7-/_. <br /> (Complete in Triplicate) SCANNED <br /> irA CI'0 <br /> _________________________________________________________ This Permit Expires 1 Year From Date Issued <br /> Date Issued 0 "2�__V <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 its fimade in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION /.t,l._ _/_�' _-__-- -- � / _v�=r__.:...-------.----CENSUS TRACT ----- <br /> Owner's Name <br /> (�-� ------------------------ -------------- --- - --- - - Phone -/-__F_2-Y7-`1 <br /> Address�_yt_8_6- - --- ---- -- `--------------------------•- City . ---- <br /> Contractor's Name -------------------- ------.License # ----------------------- Phone -------------------------_--- <br /> Installation will serve: Residence [Apartment House❑ Commercial ❑Trailer Court ;❑ <br /> Motel ❑Other -------------------------------------------- <br /> Number <br /> ------------------------------------------Number of living units:---------- Number of bedrooms --3-•----Garbage Grinder ----------- Lot Size --=-I---- ------------ <br /> Water Supply: Public System and name ---------------------------------•----------------------------------------------------------------------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Gay ❑ Peat❑ Sandy Loam ❑ 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 s ervis av1illable within 200 feet,) q <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size__�Q�, __ �Q--��/_ "�`_�_ �/Liquid Depth/__.�-.__._.___ <br /> Capacity -_r�-__00_,_- Type ____________________ Material_l�WL�_ No. Compartments __ ............. ID <br /> Distance to nearest: Well --- __________________Foundation ---------------------- Prop. Line __l_L ' -------- <br /> LEACHING LINE [ ] No. of Lines ----3--------------- Length of each line------ <br /> �_Q. --------- Total Length ---- -_-T-0__-..... <br /> _. <br /> 'D' Box ------------ Type Filter Material aYr1. &_-Depth Filter Material ............................................ <br /> Distance to nearest: Well ---Af-Q--------- <br /> Foundation ------------------------ Property Line _fid................ <br /> SEEPAGE PIT [ ) Depth c36--//-------- Diameter ---------------- Number ---------------------------- Rock Filled Yes !k No I❑ 9 <br /> Water Table Depth __ __1_-------------______________---_--Rock Size - �// <br /> Distance to nearest: Well ----- U----------------------Foundation -------------------- Prop. Line lQ._._..._..._... y <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ____________________________________________ Date ............................ <br /> SepticTank (Specify Requirements) ------------------------------------------------------------------•---------------------------•.---------------------------- <br /> DisposalField (Specify Requirements) ------•------------•------------------------------------------------------------------------------------------------- ----------- <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 /> "1 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 /> BY ------ ------------------------------------------------------------------------------------------------ Title ------------------------------------- ------------------------ <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY --------------- ---- - -_--- _ - -___ ______- DATE ---- ------------ <br /> BUILDING PERMIT ISSUED ------------------------ -----------------DATE ------------------------------------------ <br /> ADDITIONALCOMMENTS --------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> --- ----------- -- ------------ --------------- <br /> ---------------------------------------- -------------------------------------------------------------------------- <br /> ----------------------------------- - <br /> Final Inspection by: ---- ---------------- <br /> ------------------------------------------Date -- *-T-T <br /> SAN JOAQUIN LOCAL <br /> E. H. 9 1-'68 Rev. 5M <br />