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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> - - - <br /> ----------------------------- Permit No: ----7-��---9-� � <br /> (Complete in Triplicate) <br /> ---------=---------- ----- --- --------- ---------------- <br /> __- This Permit Expires f Year From Date Issued 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 i's m d n-compliance with Cou y Ordinance No. 549 and existing Rules and Regulations. <br /> ,���� N• ��., J� �> (�'. � --�-----.._CENSUS�RACT�csa�-�- ------------ <br /> JOB ADDRESS/LOCA ON - _��t-__` �.t,____,_ :_ __ -1 .- --- � <br /> Owner's Name ----- -- ----- ---- ----------------------- - -------------------------- - Phone --------------------- ------ <br /> ��/67 O Cit ,=-.-- --•------ + <br /> Address ------ --------- � --- - --- -----------!` `- Y <br /> Contractor's Name ------- - <br /> ./l---.v,e.I�- --- -------------�.tc --.---._license# 114?3*Y_ Phone ---------------- <br /> Installation will serve: Residence partment ouse-❑ Commercial ❑7railer Court ',❑ <br /> Motel ❑ Other--- -----Or," _ <br /> Number of living units_____________ Number of bedrooms ------------Garbage Grinder ------ ----- Lot Size ----- ------ <br /> Water Supply: Public System and name -------------------------------------------------------------- ------------------------ -----------------Private zt, W <br /> 4, r\ <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 /> (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,) i <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 <br /> ________.______._.:.. -SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No i❑ <br /> I <br /> Water Table Depth ---------------------:--------------------------Rock Size -------------------------- <br /> Distance to nearest: Well -----.-----------------------------------Foundation ---------------.---- Prop. Line ___________.___...__.. <br /> i <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ---------------------;-------L-------------- Date --------_-------------------------) <br /> SepticTank (Specify Requirements) -------------------------------- ----- ------------------------------------------------------:------- -------•----------------------------- <br /> Disposal Field (Specify Requirements) ------- �. � 1_d-a , - '—sem___- C <br /> (Draw existing and required ad <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> clition 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, t shall not employ any person in such manner <br /> as to become subject to Workma ompensation laws of California." <br /> Signed ------------------------------------ ---- --- - --- Owner <br /> BY - ------------ Titler[1 - <br /> (If other than owner) �x�, . <br /> U <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ...... ` ------- ------. DATE ---� 7 -- ----------- <br /> BUILDING PERMIT ISSUED ---------------------------------------------------------- ---------------------- - -- --- --------------DATE ------------------------------------------- I <br /> ADDITIONALCOMMENTS ------ - -- -- -- -- ----- - ---------- ---------------------------------------------------------------------------------------------------- <br /> ----------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------- <br /> -------------------------------------------- -------------------- --•--•- <br /> --------------------------------- <br /> - ---- = <br /> ----- -- ---- <br /> Final Inspection by. ------------------------------------------ ---- ---- ------------------------ <br /> -- ------------ Date -�---- -----~� <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M, <br />