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FOR OFFICE USE- PIPLICATION FOR SANITATION_ PERMIT <br /> (Complete in Triplicate) Permit No- --------------------- <br /> --------------------------------------------------------- This Permit Expires I Year From Date Issued <br /> 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 exist, g Rules and Regulations: <br /> JOB ADDRESS/LOCATIO -------a - -- -1 --c -----CENSUS TRACT <br /> -------------- - ------- <br /> iJ7 <br /> Owner's Name ------ - ---- - AF. cc <br /> ---Phone <br /> Address � city `� <br /> Contractor's Name ---/. � <br /> # lel7avla----- Phone - -------------------------- <br /> Installation will serve: Residence [ ] Apartment House-[] Commercial ❑Trailer Court ;❑ <br /> Motel ❑ Other -------------------------------------------- <br /> Number of living units:--- ------- Number of bedrooms _________Garbage Grinder_.----- Lot Size _ -------------------------- <br /> Water <br /> __________ ______________Water Supply: Public System and name ----------------------------------------------------- - ------------------------------------------------------Private-Al <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ,E] 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 -------------------------- <br /> Capacity -------------------- <br /> ___.____.___.__-.--___-__Ca acit 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' <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 ❑ <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) -------------------------------- ---- ----------------------------------- ---------------------- --------- <br /> Disposal Field (Specify Requirements) __ _______ _: - M. 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 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 ubject to Workman's Compensation laws of California." <br /> e' <br /> Signed ---- -- '--- - --------- Owner <br /> BY ----- --------------------------------------------------- --------------------------------------------- Title --------------------- -------------------------------------------------- <br /> (if other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY - --� - ----------------- - -- DATER ".�_q_4_er----- - __------ <br /> - -- ---------------------- <br /> BUILDING PERMIT ISSUED --- ----------------------------------- --------------DATE ------- ----------------------------- <br /> ADDITIONALCOMMENTS ------------- ------------------------------ ---------------------------- --------------=--------------------------- <br /> ----------------------------------------- <br /> ---------------------------------------- <br /> --------------- ---------------- - ------------------------------- ------- <br /> ---- ---=------- <br /> Finai Inspection bY: - -- ---- --------------------------- - -------Date `.. <br /> F <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />