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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> -- --- ---- --- --- - ----------------- <br /> (Complete in Triplicate} Permit No. '7Lr-_ __�_____.. <br /> ---------------------------------- ------ --------------- This Permit Expires 1 Year From Date Issued <br /> Date Issued _._ ___"_Z___?__'� <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 yin compliance withCountyOrdinance No. 549 and existing Rules and Regulations: <br /> /._ <br /> JOB ADDRESS/LOCATION -1.57 -- -------------------------------------------CENSUS TRACT -----------------:-------- <br /> Owner's Name - ----------------------- --------Phone -9 <br /> Address 7 •( �------------------------------ City <br /> Contractor's Name :L� z --------------------- ----------License ---- Phone -------------------_ ------- <br /> Installation will serve: Residence ❑Apartment House❑ Commercial ❑Trailer Court i❑ <br /> Motel ❑Other -----------------------=---'---------------=- �1 <br /> Number of living units_____________ Number of bedrooms ------Garbage Grinder -_t_-------- Lot Size _ S__ _-1-_ ------------- <br /> Water Supply: Public System and name ---------------------- ---------------------------------------.-------------------------------------------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand g' Silt❑ Clay ❑ PeatE]- Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe ❑ 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 /> 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 ------------.------------- I) <br /> Capacity ---- --------------- Type ----------=--------- Material---------------------- No. Compartments ----------------.:.... <br /> Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line -----•----_-•--------- .� <br /> LEACHING LINE [ ] No. of Lines ______________________ Length of each line--- ---__________-______ Total Length ------______________________ <br /> 'D' Box ------------ Type Filter Material --------------------Depth Filter. Material -------------.------------------------------ <br /> nearest: Well --------------r <br /> -__------Foundation ------------------------ Property Line -------------------- <br /> SEEPAGE PIT ( ] Depth ce tryDiameter/w'�bY.30__ Number ---I----------------------- Rock Filled Yes No 0 <br /> Water Table Depth ------------------------------------------------Rock Size ---------------------- <br /> Distance to nearest: Well ______________________________________Foundation _J_Q_-----____. Prop. Line .._.__-------- <br /> ........ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# --------------------------------------------- Date ----------------------------------) <br /> Septic Tank (Specify Requirements) ------------------ ---------------------------^------------------------------------ ---------------------------- ---------------------------- <br /> r � <br /> Disposal Field (Specify Requirements) ------------- ------------------------------------------------------------------------------------------- <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 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 __. ,( __ _ . r. Owner <br /> -------------------------------------- - <br /> By -------- ------------------------- Title ... �------------------------------------ <br /> - -- - ----------------------------- <br /> (If other than ow r <br /> ` F DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ---- ----- -- - -- - --- ----------------------------------- <br /> ------------------------ DATE ---_a Z �------------------- <br /> - <br /> BUILDING PERMIT ISSUED ---- -- -------------------------------------------------------------DATE ------ ------------------------------------ <br /> ADDITIONAL COMMENTS -- ---- - --------------------------------------------------------------------------------------------------------------------- <br /> ----------------------------------------------------- ----- --- ---- -------- ---- -- <br /> ------ <br /> --------------------------------- <br /> Final Inspection by: -------------- -------------------------------------------- -Date --- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />