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FOR OFFICE LISE: APPLICATION FOR SANITATION PERMIT <br /> --------------li----------- 'r" ------ <br /> ----"--- <br /> :_i 5�___ <br /> q (Complete in Triplicate) Permit No, �_ <br /> --- ------ - -------------------------------=---- <br /> _'--_- This Permit Expires 1 Year From Date Issued Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a per 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 /> JOB ADDRESS/LOCATION.'- 7 - _. --- -"-`______________ <br /> ----------------------------CENSIJS TRACT -------------------------- <br /> Owner s <br /> ------------•----------- <br /> Owner's i:L _ _ Gr ->�_ --------..__Phone ------------------------------------ <br /> i --------- <br /> ------.. ��- -� i-------- ---- ------- City <br /> 1 ------ ----------------•--•----------- <br /> Contractor's Name ------�i----------------------------------License # ------ Phone -------------------- - <br /> Installation will-serve: Ib ResidenceApartment House°❑ Commercial :❑Trailer Court <br /> SI <br /> ..,, <br /> t , t Number of bedrooms 3___Motel ❑Other ---- ------------=-`-=-------------=--------- <br /> Number of living units:-.--( _-�____Gfa4 <br /> _.______ rbage Grind�4±------- Lot Size <br /> ,, . <br /> Water Supply.,Public Systelm and name ........ -------------------- -------------------------------------------------------------Private' <br /> li• <br /> Character of soil to a depth:of 3 feet: Sand'❑ Silt:❑ Clay ❑ Peat❑ Sandy Loam •❑ Clay Loam ❑ <br /> ' Hardpan ❑ Adobe ❑ Fill Material If yes, type ---------------------------- <br /> ' r <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> 11 } IF <br /> NEW INSTALLATION: .(No septic tank or s � <br /> eepage pit permitted if public sewer is available within 200 feet) ' <br /> PACKAGE TREATMENT ['•]- SEP,TII TANK'[ ] Size-------------- --------------------------------- Liquid Depth .-------------------------- <br /> aacrt I Type __F________________ Mater-al_____ `_�_____ _____.__ No. Compartments ______._____ <br /> Distance to nearest: Well ________________________________Foundation ---------------------- Prop. Line ---------------------- <br /> .:....___. N14� <br /> ' <br /> LEACHING LINE ''[ J 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 C1 <br /> Water Table Depth <br /> -----------------------------------­------------Rock Size -------- ----------------------- <br /> Distance to nearest: Well _______________________________________Foundation -------------------- Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ---------------.__._______________� <br /> li <br /> Se tic Tank (Specify Re uirements) ------------------ - ----- -------------•------- <br /> p ( P Y I� <br /> s, Di s osal Field S ecif q'Requirements) L 1 Q� ' " -------i ----- <br /> ii - <br /> -------------------------- <br /> ----z ----------- ----------------- - ------------------------------------------------------------------------------------ -------------------------------------- <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 taws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- <br /> sed agents signature certifies the following: <br /> a <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 /> 1 as to become subject to Workman's Compensation laws of California." <br /> Signed -------------------- ------ Owner <br /> ----------------------------- Title �h ------------------------- <br /> (If o er th o era r <br /> OR DEPARTMENT USE ONLY <br /> BUILDING PERMIT ISSUED'BY DATE __�� '-2 3-�. ----------- <br /> BUILDING <br /> --- _- - <br /> APPLICATION ACCEPTED <br /> UILDIONAL COMMENTS ------------------------------- --------------------------------------=--------------DATE --------------------------------------------- <br /> ADDITIONAL <br /> ..--------------------------------------- <br /> ------------------------------------------='--------------'----------- --------------------------- ------------------ <br /> ------------------------------------------------------- ----------- <br /> -------------------------- -------------------------------------------------------------------------------' <br /> -------------------- <br /> -------------- <br /> ---------------------------- --------- iI- ----------- ---------------- ----------------------- <br /> Final Inspection b ' ------------------------------Date -_ - ----- <br /> SAN --- --------- <br /> J AQUIN LOCAL HEALTH DISTRICT <br /> rt <br /> E. H. 9 1-'68 Rev. 5M <br />