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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> - <br /> -------------------------=- <br /> (Complete in Triplicate) Permit No. _r.. 1 <br /> ------------------------------------- ----------------- <br /> - -----------•-------- <br /> ________________--------------- This Permit Expires 1 Year From Date Issued Date 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 o. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATI t!-![ a'i6 'o CENSUS TRACT <br /> -------------------------- <br /> C <br /> -------- ��----------- <br /> Owner's Name -- - -- -- -------- --- -- ��Sf ----------r__10-------•-- - Phone ------------------------------------ <br /> Address -------- � Y 4 � +/ City �� - ---- <br /> ------------ --- •- <br /> Can#ractor's Name -------------4..;- -__- -- --____-- _-- .License # ---� 3_ 'Phon ______----_--.---•--•--:..._ <br /> Installation will serve: Residence ❑Apartment House❑ Commercial :❑Trailer Court 0 <br /> Motel ❑Other - ----- ------- -____-- <br /> Number of livingunits.--- Number of bedrooms �"`- <br /> _ - -----Garbage Grinder ------------ Lot Size -------------------------------------------- <br /> ... ------------ -- --------------------------------------------- <br /> __Private <br /> Wa#er Supply: Public System and name ___________ ❑ <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay E] Peat❑ Sandy Loam Clay Loam E] <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--------------------------t----------------------- Liquid Depth ---------------------.----. <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 /> ,�.. . <br /> r Distance'to nearest: Well ________________________ Foundation _____._________________ Property Line ___.___.___.______._____ <br /> SEEPAGE PIT [ ] Depth --------------- Diameter ---------------- Number ________________________ Rock Filled Yes ❑ No C) <br /> t Water Table Depth ------------------------------------------------Rock <br /> Size ------------------------------•- <br /> ^" Distance to nearest: Well _______________________________________Foundation ____________________ Prop. Line ...____. .......... <br /> -REPAIR/ADDITION(Prev. Son itation Permit# -------------------------------------------- Date --------------------.-----._._..-_} <br /> Septic Tank (Specify Requirements) ---- ------------- ------------------- -------•--------- ------------------------- -------------- <br /> Disposal Field (Specify Requirements) -____ _-_ -.. -�____ <br /> r �� -- ------------------------------------- ------------ --------- <br /> -------------------------- <br /> -------- <br />' ------------------------------------------------------�---(Draw existing and required addition on reverse side)------------------------------------------ ------------- <br /> I hereb certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> �! <br /> Y Y p p pp q <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 subjeLtoorkman's Compensation laws of California." <br /> Signed - ----- --- - ---------------- ---- OwnerJ <br /> ,- _ _By -------------------------- e Title -------- <br /> (If other than owner) F <br /> . OR DEP RTMENT USE ONLY <br /> APPLICATION ACCEPTED BY __ _ __ __ _ __ _ _ ~" <br /> = DATE `5 ---------3__. ' <br /> BUILDING PERMIT ISSUED ----------- --------- ---=------ -_----------DATE ----_----=--------------- ._ <br /> --------------------------------------------------------- �-- ----------------- <br /> ADDITIONALCOMMENTS -------------'---------------------------------------------•-----------------------y---------------------------------------••-------------------------------- <br /> i <br /> i <br /> --------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ----------------------------------- ---- -- -- -------------------------------------------------------------------------------- r <br /> --- ----- -- ----- - ------ <br /> - - <br /> Final Inspection by: ------------------------------- ----.Date 4---------------- �� -` <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />