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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> ` Permit No. -� __/�`�4 <br /> -------------------------------------------------- <br /> .�- (Complete in Triplicate) <br /> -------- --------------------------------- <br /> This Permit Expires 1 Year From Date Issued bate 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 /> �S` 1"�` CENSUS TRACT <br /> JOB ADDRESS/LOCATION ---- - l 9 ----------------------- <br /> Owner's Na e __"�? f� �` ------------------ ------------------- - -- -----:----------Phone ------------------------------------ <br /> Address,,%. ------------ ------------------ -----------------------•-- --. City. ------------------------------------- <br /> -- <br /> ------ <br /> F <br /> Contractor's Name ------------------ ------ --------License # _ 1� __ Phone -- A�l <br /> Installation will serve: Residence ❑ Apartment House 0 Commercial ;❑Trailer Court ;❑ <br /> Motel E]Other <br /> ---------------------- <br /> Number <br /> ---------Number of living units------------- Number of b 4roo s --/-----Garbo e Grinder ---- Lot Size - --------•-__ ' <br /> Water Supply; Public System and name ______ _C_ `-� <br /> �' Private ❑ <br /> Character of soil to a depth of 3 feet: Sand'❑ Si It Clay ❑ Peat❑ Sandy Loam ❑ Clay-Loam:❑ <br /> Hardpan ❑ AdobeX Fill Material ------------ If yes, type ___________________________ <br /> k <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,) U, <br /> PACKAGE TREATMENT [ 3 SEPTIC TANK:[L' Size_ ��� _ S _`--_ _ _ ______ Liquid Depth ------1;/ G+ <br /> 7 -- <br /> �''���` Capacity 1 --___ <br /> Type -- Material_ - ___-- No. Compartments .............. <br /> Distance to nearest: Well __________Foundation __/!---- -------- Prop. Line `!-- <br /> LEACHING LINE [ No. of Lines --------/------------ Length of each line---- <br /> ----------------- --------Total Length -______..__._... <br /> 'D' Box ------------ Type Filter Material '` Q!*-Depth Filter Material ____.__`_ ________________y_,_,_,__._--_. <br /> Distance to nearest: Well Foundation ----A03_f________ Property Line <br /> -------------- <br /> SEEPAGE <br /> 3 <br /> k •, <br /> SEEPAGE PIT [yK Depth __ _________ Diameter 2-_______ Number -----------`_____________ Rock Filled Yes No i❑ <br /> 1 / t <br /> 4 Water Table Depth ------5&-----------------------------------Rock Size - ------------- r <br /> Distance to nearest: Well ______ ____________________Foundation __ _ _._____ Prop. Line ........ ?� _ <br /> REPAIR/ADDITION(Prey. 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 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 beco a subject to Workman's Compensation laws of California." <br /> Signed ------- - <br /> ---- Owner <br /> ��-�-- ------=------- -------- --- --------------- Title ------------------- ---------------------------------------------------- <br /> YO <br /> other than owner) - <br /> OR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY `Q ------- ---------------------------------------------------- DATE � '���-(� -------------- <br /> BUILDINGPERMIT ISSUED ------------------------------------------------- -------------------------------------------------------DATE ------------------------------------------- <br /> fADDITIONAL COMMENTS -------------------- ------------------------------------------------------------------------------------------------------------ --------------------------- <br /> ---------------------------------- ----------------------------------------------------------- ------------------------------------------------------ <br /> --------------------------------------- - - ------------------------------------------------------------------------------------------ ----- ----- <br /> Final <br /> -- fFina! Inspection by: -- - --Date ------------------------ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />