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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> ---- ---- - - ---------- -------------- Permit No. <br /> (Complete in Triplicate) <br /> ---------------------- ---------------------------------- <br /> Date Issued <br /> --------------------------- --------------- This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to the San Jo tquin 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 /> JOB ADDRESS/LOC ON ad _-.�._ - -�'�-5)��� id__ �`°�p'CENSUS TRACT -------------------------- <br /> Owner's Name -------- - ----- -- - ----------- -- - ---------?5 ----------------------------/-=�- -------Phone ----------------------------------.. <br /> Address ---- — d� -- --- - . City ----CZa- ---------------------------------.._...---- <br /> Contractor's Name �0 � ---- - ----- ------ - .License #� 3 �'. Phone <br /> Installation will serve: Residence ❑Apartment House❑ C mmercial ❑Trailer Court i❑ <br /> Motel ❑Other <br /> Number of living units:-----I---- Number of bedrooms --Z-----Garbage Grinder _ --------- Lot Size _- _-_-- - - <br /> _- - --_------------- <br /> Water Supply: Public System and name ---------------------- -------------------------------=----------------------------- rivate ) <br /> Character of soil to a depth of 3 feet: Sand'EJ Silt❑ Clay ❑ Peat❑ Sandy Loam; Clay Loa <br /> Hardpan ❑ Adobe ❑ Fill Material ------------ If yes,type ---------------------------- <br /> (Plot <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 [ I SEPTIC TANK Size0---1-,-f-51 11----------- Liquid Depth ___fZ------------- ----- <br /> Capacity, Type Material X?4'X�----- No. Compartments --_�.._-.-_... . <br /> Distance to ne rest: Well �----------, v - ---------------Foundation ----1®-___------- Prop. Line ._.a` _--_-- <br /> LEACHING LINE [ No. of Lines --------/--------------- Length of each.-line------ _----_____-_ Total Length bQo--_---.._---.-__. <br /> hD' Box - __-.-_ Type Filter Material __5 --______Depth Filter Material _____lf <br /> Distance to nearest: Well _______: P_.---------Foundation --------1_Q---------- Property Line. ----------------------- <br /> [ Depth --- ----- ----- „gie#era_ ----U-=_ Number ---------- --------------- Rock Filled Yes No [IZ IV <br /> Water Table Depth ----------------I-a-------------------------Rock Size --------- ' <br /> 4 Distance to nearest: Well ----------1�P-f-------------------Foundation ___,'�7-------- Prop. Line __S.___._.......-- <br /> ' REPAIR/ADDITION(Prev. Sanitation Permit# -------- --------------------------.---------- Date -------------------------------- <br /> Septic <br /> ------------------------------Septic Tank (Specify Requirements) ---------------------- , <br /> DisposalField (Specify Requirements) --------------------------------------e------------------------------------------------ -------------------------------------------- . <br /> ---------------------------- -- ---------------------------------------------------------------------------------------�-------------------------------------------------------------- - <br /> ------------------------- ------------------------------------------------------------------------------ -------------------------------------------------------- <br /> (Draw existing and required addition on reverse side) <br /> 1 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, 1 shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed -.- ,.. .. — - :-_ Own <br /> BY - Title W4.4'------------------------------------- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -- = - -------------- DATE ------W--------------------------- <br /> -------- <br /> - - -------------------------------- -- <br /> BUILDINGPERMIT ISSUED ------ ------------------------------------------------------------------------------------=--------------DATE - ----------------------- ----------------- <br /> ADDITIONALCOMMENTS -- --------------------------------•------------------------------•--------------------- -----------------------------------------------------•---------------- <br /> -------------------------------------------------------------------- -----------------------------------------------------------------------------------------------------------�40- <br /> Final <br /> - <br /> ----------------------------- -------------------------- -------------- ----------- --------------------------------------------- <br /> -------- <br /> l Inspection b Date ..--____---1/_---------------------------------------------------------------- ---- ---- - - -- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> E. H. 9 1-'68 Rev. 5M <br />