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FOR OFFICE USE: <br /> 2 ' 3Z APPLICATION FOR SANITATION PERMIT i <br /> (Comp rte in Triplicate) Permit <br /> This Permit Expires 1 Year From Date Issued <br /> Date Issued <br /> _ <br /> --_ -------------------------------------------- _ <br /> -- ___ <br /> fa�` 5aEt6E�'Tlt�£,wra' ©L6 ? ?2� ©_5' <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein <br /> UiMp-idescribed. This application is co pl n e id Cou}3 ;�rd- e 54 exi tin Rule a Re a <br /> . , <br /> JOB ADDRESS/LOCATION _277/4-1-- --- ------ - - --- ------- - - ----- ---- -----------%3.73.CENSUS TRACT ---------------------_---- <br /> •- --Phone ------ <br /> S Name .- -- - - - --- --------- --- ------ ---- -- -- - -- -- -------------------------- ----- ---- <br /> �/ _ <br /> Address /v - --------- -�- ------- - - ------ ---- -------------- city <br /> _ - - !/!- - ---- <br /> Contractor's Name - License # ------- Phone . <br /> Installation will serve: Residence XApartment House❑ Commercial ❑Trailer Court <br /> Motel ❑Other -------------------------------------------- <br /> Number of living units:---j---.-- 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'❑ Si It Clay ❑ Peat Sandy Loarn�''*Clay Loa1n []Y <br /> Hardpan E] Adobe E:] "Fill'Fill Mate __,__ __-__ If yes, type __.________--____-_-__.__ <br /> 1 � <br /> (Plot plan, showing size of-lot, location of system in relation to wells, buildings,=itc:-must'be`placed.on reverse side.) <br /> NEW INSTALLATION: y (No septic-tank ores epage pit permitted,; public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT-[] SEPTIC TANK'[ ] Size------------------------------------------------ Liquid Depth --------------------------- <br /> Capacity <br /> ------- -----Capacity -------------------- Type -------------------- Material---------------------- No. Compartments ------•-------------_ <br /> Distance to nearest: Well ------------------------------------Fou-ndation ---------------------- Prop. Line ---------------------- <br /> AL <br /> ;LEACHING LINE [ ] No.lof Lines I �` -------- Length of each line---------------------------- Total Length ___________.____---_________ <br /> 1 D Box --------____ Type Filter Material f-- --------------------Depth Filter Material --------------------------------- ---------- <br /> ' Distance'to nearest: Well ----------------------.- Foundation ------ ----------------- Property Line - <br /> i <br /> i _-_ Number --_-----------_._________ Rock Filled Yes No <br /> 5EEPAGEPIT [ ] Depth --___-._:_�_- -_ Diameter ------------- ❑ ❑ <br /> I Water Table Depth __Rock Size ____-______.____._ Vii' <br /> REPAIR ADDITION ---------------------------------------------' <br /> Distance to`nearest: Well -- -------------------------------------Foundation -------------------- Pro Line ----._---------------- <br /> / (Prev..( tI - �+ <br /> .sanitation Permit#, Date ------------------------------- --} <br /> Septic Tank (Specify Requirements),--- J_-____.--------------- ------------ --------------------- - <br /> Disposal Field (Specify`Requirerments) ------------- aa4l----- ------- U --------------------------------------------------- <br /> a <br /> ng and required ad--------------------------------- <br /> {Draw <br /> --------------------------------- -- <br /> --------------------------- -- <br /> dition on reverse side) <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San JoaquV4 <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: r <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 ---------------------- Owner <br /> Ti#le ------------------ <br /> BY ------ (If than owner) <br /> OR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ---------------------------------------------------------- DATE --------------- <br /> BUILDING PERMIT ISSUED ------------------------------------ -----DATE ----------------__ <br /> ADDITIONALCOMMENTS --------------------------------------------- ------------------------------------- ----------------------------------------------=--------------- ------- <br /> ------- ---- <br /> ----------------------------- ------------------------------------------------------------------ --------- ---- ---------------------------------------- <br /> --- -------------- <br /> -------------------------------------------------------------------------- -------- - - <br /> ----------------------------------- ------ --------- --------------------------------------------------------------------------------------- <br /> - 4- <br /> {-�---- -�(-- <br /> FinalInspection by- - -----`-'�-�.r-- ----- --------------------------------------------------------------------------------------,Date ------------------------- ----- - ------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'66 Rev. 5M <br />