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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ------------------------------------ <br /> (Complete in Triplicate) Permit No./0_____657 <br /> This Permit Expires T Year From Date Issued Date Issued -. /7:-2b <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 incompliancewith County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION .-- "-_--- -!- --- �,--- r- -- -- ` <br /> = CENSUS TRACT �pie <br /> - <br /> Owner's Name /gXv : -_ - <br /> Phone <br /> Address -dr,---- - f city ---------------------------------_. ------�------------- <br /> y <br /> Contractor's Name --------------- ------------------------------- <br /> ---------------------.License # ------- ----------------- Phone ----- ------ ------------- <br /> Installation will serve: Residence ❑Apartment House[] Commercial :❑Trailer Court 0 <br /> Motel ❑Other -------------------------------------------- <br /> Number of living units------------- 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'❑ Silt[( Clay ❑ Peat❑ Sandy Loam •0 Clay Loam 0 <br /> Hardpan ❑ Adobe-0 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.) Ll <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK f ] Size------------------------------------------------ Liquid Depth -------------------------- N4,1- <br /> Capacity <br /> imCapacity -----------------.-- 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 /> Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line -------_._-__-_--------- <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number - -------------------------- Rock Filled Yes ❑ No 0 <br /> Water Table Depth ------------------------------------------------Rock Size ------------------------ <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ---------------------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- <br /> SepticTank (Specify Requirements) ------------------------------------- ------------------------------------------------------------------------ -- --------------- <br /> .c. <br /> Disposal Field (Specify Requirements) __ ------------------ _-------__---e <br /> ------------------c+3 -- ---r 4--------:-------------------------------------------------------------------------------------------------- <br /> f <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 subject to Workman's Compensation laws of California." <br /> Signed <br /> y __ ` �.-- _- f�, a----------------------------------- Owner <br /> By ------------------------------ - ----- ------------------- Title --------- ------- <br /> --- ------ -- <br /> (if other than owner) <br /> ,r FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -- ------ ------------------------------------------------------------ DATE .?--'-,-,?-- ---- ---- ---------- <br /> BUILDINGPERMIT ISSUED ----------------------------------------------------------------------------------------------------------DATE ------------------------------------------- <br /> ADDITIONAL COMMENTS -- ----- -- -- --- <br /> ---------------- --------------- -�'�� - �,�?�l/ -- --------- <br /> -1 <br /> ------- <br /> 10Z <br /> -- = -------------------------------!/ - -------- <br /> ----------- --------- `------- - ---- --- --------- ------------- ------- --- ------ <br /> Final Inspection by: ----- -------Date ---- ----------- - - - ---------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br /> i <br />