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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> ---------------- ------------- --------------------I <br /> Permit No: -�� <br /> (Complete in Triplicate) <br /> -------------- ------------------------ Date Issued <br /> __ This Permit Expires ] Year From 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 is.made ini.compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION _ �I �1� - ''� = -CENSUS TRACT --------- ---- ,---.. <br /> Owner's Name p ----P e - --------------------------=-----• <br /> - <br /> --- - <br /> Cit --------------------•-------------- <br /> Address -------- -------- --------' , Y <br /> ------------------------ --_- <br /> Contrac:tor's Name -.._ <br /> t�iEQ.License # .1,9e�4F_� Phone --------------------------• -- <br /> Installation will serve: Resid ce EllApartment House❑ Commercial:[]Trailer Court i❑ <br /> 1 <br /> Motel ❑Other -------------------------------------------- 1 <br /> Number of living.units:--.... ----. Number of bedrooms -----I-----Garbage Grinder ----- Lot Size --.-___--.------.'------------- ----__---- <br /> Water Supply: Public System and name ------------------ ---------------------------------- --------------------------------------------------------Private <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt El Clay .❑ Peat ❑ Sandy Loam .E] Clay Loam M <br /> Hardpan � Adobe ❑ Fill Material --- If yes,type ---------------------------- <br /> (Plot plan,: showing size of lot, location of system'iri-relation to wells, buildings; etc. must be:.placed on reverse side.) <br /> t. <br /> NEW INSTALLATION:, (No septic tank or seepage pit_perrrmitted if public sewer is available within 200 feet,) <br /> xy <br /> PACKAGE TREATMENT ( ] SEPTIC TANK'{ I Size----------- -------- -=-----'--.•---- ------- Liquid Depth - ------------------------ fi\ <br /> # Capacity ------------ ------- TVp6 Material ------------ No. Compartments --------•--------= J, <br /> Distance to nearest: Well ------------------------------------Foundation ------',--.Prop. Line ------------..-.-------- <br /> LEACHINGLINE ( ]—No. of-L]nes - --------------- Length"of"each liner --------t-`------- ------ Total-Length ----:---------- ------ �y <br /> 'D' Box ------------ Type Filter Material --------------------Depth Filter Material ----------------------------------- ---�-- <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 /> Septic Tank (Specify Requirements) ------ ---- r ------------ ----------1- .......... <br /> Disposal Field (Specify Requirements) A- -------- -��---X- ` - - ----------------------- <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`nr`licen- <br /> sed agents signature certifies the following: I <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." t f <br /> f <br />� Signed ----- - ----------- -------------------- - ----- -- -- --- - - - Owner <br /> - p <br /> BY ► ... ......'i". <br /> - ----- Title U-U---- ........­ ­-----i---------- <br /> - <br /> (If other than owner) $ <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ----- -- - - - ------------------------- ---------------------------- DATE _ ' --�'-71- <br /> BUILDING PERMIT ISSUED --- ---------=------ - ---- -------------------------- <br /> - -- --- --------=--------- DATE_. <br /> ---- <br /> - <br /> ADDITIONALCOMMENTS ----t------ -------------------------------------------------------------- ---------- --------------------------------------------------------------- --------- <br /> ---------------------------------------- <br /> i --------------------------------------- ------------------------------------ ------------------------ ------------ ------------------------------ ------- <br /> - ------------------------------- <br /> ---- -- -- ------- -- <br /> ........... <br /> Final Inspection by: ---- Date - - ` 7�- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> I E. H. 9 1-'68 Rev. 5M <br />