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FOR OFFICE USE.- APPLICATION FOR SANITATION PERMIT <br /> .............. d'._ <br /> .._ ._... <br /> .. . <br /> n Triplicate) Permit o . . �� <br /> #Complete I <br /> ...:.....:...:......:...:......:.... : � _h_7 <br /> Date Issued ---'...:...... ... <br /> This Permit Expires 1 Year from Date Issued <br /> Application is hereby made to the Son Joaquin Local Health District for a permit to construct and install the work herein <br /> described. This application is made in compliance with q0unty Ord once No. 549 and existing Rules and Regulations: ' <br /> f CENSUS TRACT .......................... <br /> JOB ADDRESS/LOCATION ....... � <br /> Owner's Name ._.. f" --.. ...I ...:......•..................................................Ph •........•••..._ <br /> Address .... ........ ..... .........I......... ..... .. . City ...................... <br /> ...,........,......... <br /> .. tetLicense .,�./ li.f� . Phone{�!........... ....7 <br /> Contractor's Name --....-. � f .. • <br /> Installation will serve: � esid n e❑Apartment House�,] Commercial ❑Troller Court C] <br /> Motel ❑Other ......_.. -` <br /> Number of living units:... Number of-bedrooms q Garbage Grinder Lot Size ••••L• <br /> Water Supply: Public System and name ........................... ......:-,--•-=...........................:..........................Private <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt[] Clay 0 Peat E] Sandy loam fl Clay Loam <br /> _ .. — Hardpan O Adobe L] Fill Material ............ If yes,type ... . .I.... ............ <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 j l Size...? ....-•................................... Liquid Depth ........--,---............5 <br /> Capacity -------------------„Type------------ Material.-----------.......... No. Compartments •.. .............. <br /> =. eaeWProp. Line ... ...Distance„tr . ti ..'... . <br /> LEACHING LINE j No-of 1.14r.. -0........_.". length of each line-_ ...... Total Length .................... , <br /> 'D' Box ---------._ Type Filter Material ....................Depth .Filter Material ............................................ e <br /> I Distance to nearest: Well .........-.............. Foundation Property Line ........................ [, <br /> SEEPAGE PIT ( } Depth V.1? Diameter Number ...... ..................... Rock Filled Yes ❑ No ❑ a <br /> Water Ruble Depth ..................................... Rock Size ..............------••............ 0 <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) ------------------------------------------------------------------------............................................................... <br /> -�� <br /> ................................................... <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-aecordan+ce;-with_.Sanr Joaquin <br /> Rules and Regulations of the San Joaquin Local Health,District. Home owner or licen- <br /> County-Ordinance's;"S+ate"Laws,and <br /> sed agents signature certifies the following: <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 /> -- •--•-------- Title <br /> BY ------•--- ...---�f oche th-- - o n( . �- _ _ - ----------------•-• --- <br /> • <br /> It DE ARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ----- ---._.:._----:--._.._...--.-----... .. ._------�--- .............. ..�: .� _ � :. <br /> BUILDING"PERMIT"ISSUED --7- DATE _.._...... .... <br /> ADDITIONAL COMMENTS ---- - --- •.._.. .... -------------- ----- ---•------...---.._.._.... <br /> -•--•-....-- <br /> ............................... ...................................,...... <br /> Final Inspection by: ..----- ----- . ... .- . •........Date ....j?.:/.�- ........... .... <br /> EH 13 24 1-68 SA JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M� <br />