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FOR OFFICE USE; APPLICATION FOR SANITATION PERMIT <br /> -------------- ------------------------------ ----- <br /> (Complete in Triplicate) Permit No __<_______ <br /> Z" Date Issued <br /> ----------------------------------------------------_-__ This Permit Expires ] Year From 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 .__. a .--- -f------,U-/- _�'r�i�------A0------------------------ TRACT -------------------------- <br /> Owner's Name -- 11/? ------ �--X61-_ ----------------------- - ---------------- -------Phone <br /> . <br /> Address .--- ---. -��-�'��------------------------ --------------------------------------------- <br /> - -. City e�111,�2-11J -------------------------------------------------- <br /> ------------------------------ <br /> Contractor's Name "--------fit' ------------------------License ------ Phone . _ <br /> Installation will serve;-Residence•54-Apartment-House❑ Commercial :❑Trailer Court ;❑ <br /> l Motel F-1Other --------------=----------------------------- <br /> Number of livingunits:_____ ._____ Number of bedrooms - Garba a Grinder _/�1}.-- Lot Size <br /> Water Supply: Public System and name ----------------------------------------------------------------------------------------------- ---------------Private <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam:11 <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 --------------------------------------- 0 <br /> Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line ------------------------ <br /> ZSEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number ------------------.'A.----- Rock Filled Yes '❑ No C <br /> Water Table Depth --------------------------------------------Rock Size ----==------------------------- <br /> Distance to nearest: Well ----------------------------------------Foundation----i----------.---- Prop. Line ...____.._.._ --------C7 <br /> REPAIR/ADDITION(Prey. Sanitation Permit# -------------------------------------------- Date --------.........-.._---_---_---_-) <br /> i <br /> Septic Tank (Specify Requirements) ---- --------------------------------------------------------------- ----------------------------_<.-------------- ............ <br /> Disposal Field (Specify Requirements) 1 ------ �---------------- •--------------- 11 <br /> ---- - --- ------------- -------------- -ra'' :Fi <br /> r <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 manners <br /> as to become subject to Workman's Compensation laws of California." , <br /> Signed ------- -- ------------- --- Owner Owner <br /> yam`-------- Title ----------------------------------------------------------- ------------ <br /> (if other than ow r) <br /> FOR .DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ----------------------------------------------------------------------------- DATE ------ r -----1-4--------------- <br /> BUILDINGPERMIT ISSUED --- ----- ----------------------------------------------------------- ------------------- --------------DATE ------------------------------------------- <br /> ADDITIONAL COMMENTS --- - ---------------------------------------------------------------------------=--------------------------- <br /> ----------------------------------- <br /> -------------------------------------------------------------------------------------------------- <br /> ------ <br /> Final Inspection by: _• ----- ----------------------=----------------------------------Date -� ----- -.- <br /> SAN JOAQUIN LOCAL HrA C'rk DISTRICT <br /> E. H. 9 1-'68 Rev. 5M. <br /> i <br />