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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit No. ------_----_------ -. <br /> ------------------------------------ This Permit Expires 1 Year From Date Issued 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 in compliance with County Ordinance No. 549 and existing Rules and Regulations. <br /> JOB ADDRESS/LOCATION ----It2 -li�— ------ -------- ------------------- - ------CENSUS TRACT <br /> Owner's Name _ { <br /> --- �-" t- - - _ -- -----------------=--------------------------------- -------- ---------Phone.- .�_�D'.��j'' <br /> Address .-; City ------------------ <br /> -------------------------•------ <br /> Contractor's Name ---__- _ _ c ------------- License # �a--��- ' Phone - 32 <br /> Installation will serve. ResidencekApartment House f:] Commercial ❑Trailer Court in = <br /> d <br /> Motel E] Other ------- ----- ----------------------------- �- -- --- ----------------- <br /> Water '1). <br /> Number of living units:--"_ --- Number of bedr ours ----� -__Garbage Grinder) _- Lot Size -_ '` � y <br /> Supply; Public System and name -_-- ,rw <br /> - --------�----� ----- -'�--�---------------------- ------•--------...-------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe X Fill Materia! ------------ 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.) W <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 --_---__-__-_-------__ ! <br /> ------------Foundation --- -- ------------ Prop. Line -------------:_...---- <br /> LEACHING LINE [, No. of Lines -----------ol--------- Length of each line___ _ --------------- Total Length :_ ------------- •v <br /> D' Box .---/---- Type Filter Material - -- ------Depth Filter Material � --'-----•'-------•----------•-_ <br /> Distance o <br /> = iI <br /> nearest: Wellf <br /> -�'--ttlre'�"P Foundation -- -- �--e --------- Property Line,-��- " -- <br /> - - -------- ---- <br /> SEEPAGE PIT R,}� Depth �_ '_� Diameter �• � Number ------/__________________ Rock Filled_. Yes L2� No 0 <br /> Water Table-Depth -------- ---------------------------------------Rock Sizer --------- - - - <br /> ' �• i <br /> Distance to nearest: Well --,Foundation -� _-_------_ Prop. Line ----k--__--__- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------- ----------------------------------- Date <br /> --------------- <br /> Septic Tank (Specify Requirements) -------------------------------------- ------ -- ------------------ ------- <br /> Disposal Field (Specify Requirements) ------ <br /> --------- r�+<<----- <br /> ------ ------------------------------------- <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'themSan;JoaquinAccal.Health District. Home owner or licen- <br /> sed agents signature certifies the following: z r"rye <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 ------------ --- .---- -- --- <br /> Owner <br /> - ----- <br /> BY ---- �; -. -- ----------- --i -Title -------- ±� <br /> ---------------------------- <br /> {!f other than owner) � <br /> I F R .DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY C-,, .-P-- -- -_"--- DATE ------------------------------------------- <br /> ---------- -PERMIT ISSUED - ---------- - DATE <br /> ---- f <br /> --------------- --------------------- <br /> D1TlONAL COMMENTS -________ ______--_-_-__ - { <br /> ---- --------------------------------------------------------------------------------------------------------------------------------------------------=------------------------------------------------- <br /> ------- ---------------------------- <br /> ----------------- <br /> --- --- ----------------------------------------------------------------------------------------- <br /> Fina! Inspection by: - - Date - �j ------- <br /> ------- <br /> ----------- ------ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> . E. H. 9 1-'68 Rev. 5M <br />