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w <br /> FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ------------ ------------- <br /> (Complete in Triplicate) Permit No. <br /> -._ _______________________________ This Permit Expires 1 Year From Date Issued yL <br /> Date Issued - ,�/ -,9 <br /> _F <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 is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION _ !- -- _ _ - '--l"°---�_-?=, ---- --_. _fi' ..........CENSUS TRACT <br /> Owner's Name ----- s '" -- ---- A-5_/�-- - - -------Phone _-`. <br /> Address -------------!P" =r.Ii '`�f' j += }• _. r <br /> City .y ,�` <br /> Contractor's Name ---- " ^ - ^ --- '' ``! <br /> --------License # l�Z_- _ __ Phone <br /> Installation will serve. Residence ❑Apartment House❑ Commercial ❑Trailer Court ;❑ <br /> Motel ❑ Other --'--f------- --........ ------ .f y l (3) <br /> Number of living units:------------ Number of bedrooms ------------Garbage Grinder -A-------- Lot Size f' _ ____ YtT_ ___________ <br /> WaterSupply: Public System and name -------------------------------•------------•------'------------------------•------------------------ ------.Private [ <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 <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: JNo septic tank or seepage pit permitted if public sewer is available within 200 feet,] `� <br /> PACKAGE TREATMENT [ ] SEPTIC TANK[ ] Size_____________________________________ _ ______ Liquid Depth --------------------_._ J <br /> Capacity -------------------- Type ------ Material---------------------- No. Compartments _.__-_.... ........... <br /> Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ------------_--_---.-- <br /> LEACHING LINE [ j No. of Lines ------------------------ Length of each line--------------------- ------ Total Length _____--_._-________________ <br /> 'D' Box ----------_ Type Filter Material ---------------y----Depth Filter Material -------------------------------------------- . <br /> } <br /> Distance to nearest: Well ----------- ------------- Foundation ....{------------------ Property Line ________________________ <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number ___________________________ Rock Filled Yes ❑ No 0 <br /> Water Table Depth ------------------------------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ---------------------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ____________________________________________ Date ----------------------------------) <br /> SepticTank (Specify Requirements) ------------------------------------------------------------------•----- ------------------------------------------------•-- <br /> Disposal Field (Specify Requirements) ------ ---------- -� '�_ J --------------------- r rte ` <br /> e --------------- <br /> ---------- <br /> -----------------F d i � : .' ------------------------------------ --------- <br /> ------------------- ----------- --------------------------------- <br /> ---------------------------------- --- ---------------------------- N <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 manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed n c.- �.y------/----5 -&------------------------------- Owner <br /> By ------- '`- _ " --------- ------------------------------ Title ....... .......x. .r. ........4 ------------------------------------------ <br /> {If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY --- - -----. DATE ��� �T L................ <br /> BUILDING PERMIT ISSUED ------------------------------------------------------------ <br /> - --------- ---------------------------------DATE <br /> ADDITIONAL COMMENTS'--------------------------------------- = - <br /> ---------- ------------------------------------------------------------------------------- ----------------------------------------- --------------------- <br /> --------------------------- <br /> --------------------------------------------------------------------------------------------------------- ------------- - - - <br /> ------------------------------- ----------------- --------------------------------- -------------- <br /> Final Inspection b - <br /> P Y • ------ -- -- -Date 1=1r�------ ------- <br /> 5AN JOAQUI L AL HEE RICT <br /> E. H. 9 1-'68 Rev. 5M <br />