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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> --------------------- _. - _. <br /> {Complete in Triplicate} Permit No. <br /> -- --------- <br /> Date Issued <br /> -------------------------------- .------------------ This Permit Expires 1 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/LOCA ION .X__541.5_7------>t.0_4- ` - ----------- --CENSUS TRACT -----------------•-------- <br /> Owner's Name ------ I <br /> -- • ---- _ -------------------------------------------=------ --------------Phone --------------------------------•--- <br /> Address ---------- �- /1!-- ---c- ---__----------------- ------- City ------ ''7T ----------------------------------------•-- <br /> Contractor's Name ------ ---- "" ---�"" ^-----.License # _J Phone --------------------------- <br /> k <br /> Installation will serve: Residence Apartment House❑ Commercial ❑Trailer Court <br /> i Motel ❑Other ------------------------- ------------------ <br /> Number of living units:-------- Number of bedrooms _ __--Garbage Grinder ------------ 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%❑ <br /> } Hardpan E] Adabe ❑—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 /> s: <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is-available within 200 feet,j <br /> PACKAGE TREATMENT :[ I SEPTIC TANK'[ ] Sized= - --------------------- ----------------- Liquid Depth ----------------------.--- <br /> CapacitY -------------------- Type -------------------- Material---------------------- No. Compartments ------ -----------•-•- i <br /> r Distance, to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ---------------------- <br /> LEACHING LINE [ ] No. of Lines ________________________ Length of line_._______'____.______..____ Total Length ,______.___,________________ <br /> 'D' Box ------- -__ Type Filter Material ____-__--____---Depths Filter Material v <br /> 4¢ Distance to nearest: Well ---------------------s_ Foundation -----_---_ ------------- Property Line ------------------------ f <br /> SEEPAGE PIT [ ]� ;Depth _____-----.-- ---- Diameter _________._._i'Numbers'--------------------------- Rock Filled Yes ❑ Na i❑ <br /> # Water Table Depth ------------------------------------------- - Rock Size ---------------------------- <br /> Well <br /> - ---------------------•--•---- ' <br /> Distance to nearest: Well ----------------------------•-----------Foundation ---------------..._. Prop. Line --------.-------__-.-- <br /> REPAIR:/ADDITION(Prev. Sanitation Permit# --------------------------------------------`Date --------------_----.--------------I <br /> SepticTank (Specify Requirements) -------------------------------------------------------- ;------------------- --------------------------------------------------------• i <br /> Disposal Field.(specify Requirements) ----- ---- ---- ---- - --- <br /> - ' --- ----------------- <br /> --------------- <br /> ' <br /> ------ ' <br /> ------------------- ------ -----------i----------------------------------------------------- - ---------=------ -------------------------------------------------------------------------------------- <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, 1 shall not employ any person in such manner <br /> as to become subject t rkman's Comp nsation laws of California." <br /> Signed ---------- - -------- Owner <br /> ---- -- Title -- � c-[r <br /> ----------------------------- <br /> (If other t an owner) <br /> x <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ____ _ _____ ____ __-_--_ --------------------- <br /> ---------------------------------------- DATEb 3 <br /> -------------- <br /> BUILDINGPERMIT ISSUED ----------------------------------------------------------------------------------------------------- ----DATE - --- ------ ----------------------------- <br /> ADDITIONALCOMMENTS ------------------------------------------------------------------------------------------- ------ --------------------------------=--------------------------- <br /> ------------------------ --------------------------------------------------------------------------------------------------------------------------------- <br /> ------------------------------------------------------------------------------------------------- -------- ------- <br /> ------- ---- - - -----.- <br /> - ��y�� <br /> Final Inspection by: _ - Date/ -------- <br /> ----------------------------------------------------------------------------- <br /> -------------------------- --------- <br /> - ---- --- - ---- -- <br /> SAN JOAQUIN LOCAL HEALTH .DISTRICT <br /> E. H. 9 1-'66 Rev. 5M <br />