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FOR OFFICE USE: +' <br /> - -- --------7-/--- � _ <br /> APPLICATION FOR SANITATION PERMIT <br /> �.. <br /> (Complete in Triplicate) Permit No: - `:5 � <br /> ---------=------------------------- ----- <br /> �i Date Issued <br /> -------------------------- This Permit Expires 1 Year From Date issued <br /> I <br /> Application is hereby made to the San Joaquin Local Health Districf 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 /> JOB ADDRESS/L ATION .-- -- - r ------------------------ - .---CENSUS TRACT -------:--------------- <br /> Owner's <br /> -- -----.Owner's Name - --------------------------------------------------------Phone <br /> Contractor's Name - -------- ----- - --------- -------- ---------- City -------------------------------- ------------- --------------- -- -- <br /> Address -------- - ---- <br /> �­ <br /> ------ Phone -��6�- � <br /> Installation will serve: Reside nce+ Apartment House❑ Commercial :❑Trailer Court 'El <br /> Motel ❑Other -------------- ------ ----------------- j <br /> Number of living units:__"- _.- Number of bedroo s -.- --_Garbage rinder - Lot Size _-gar{-U-_ --/11 , -_ <br /> k Water Supply: Public System andname ---------------------------------Private E]r Character of soil to a depth of 3 feet: Sand'❑ Silt E] Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> b <br /> t Hardpan E]3 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 /> i NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,] 0 <br /> PACKAGE TREATMENT SEPTIC TANK' Size 7 [ ] Liquid Depth ----------------------•--- `\, <br /> Capacity -------------------- Type -------------------- Material-------------- ----- . No. Compartments ---------------------- v <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 /> I Distance to nearest. Well ------------------------ Foundation ----------- ------ -- Property Line <br /> SEEPAGE PIT [ ] Depth ----------- -- _ _--- Diameter ____ _ __-___- Number ---------------------------- Rock Filled Yes ❑ No i❑ <br /> - <br /> Water Table Depth ------------------------------------------------Rock Size -- --------------- <br /> Distance to nearest: Well ___-_____-----------------------------Foundation -------------------- Prop. Line ----_._---------_----. <br /> ' REPAIR/ADDITION(Prev. Sanitation Permit x# -------------------------------------------- Date ----.------------------------_-_--] <br /> ! Septic Tank (Specify Requirements) --- ----------------------- i <br /> i <br /> DiZ <br /> l Fiel sSpecify Requir menu] -_- .- -. ---- <br /> de <br /> ------ . 11 .��---- --—-------------------------------------------------------------------------------------------------------- ----------------------- <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: y <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 ub' ct to Workman's Compensation laws of California." <br /> I <br /> Signed _ --------------- Owner <br /> BY ----- ------------------------ ----• Title ------------------- <br /> F <br /> (If of er than ow <br /> FOR DEPARTMENT USE ONLY <br /> 4 <br /> APPLICATION ACCEPTED BY ----------- DATE 7= " <br /> BUILDING PERMIT ISSUED DATE ------------------------------------------- <br /> ADDITIONAL COMMENTS ---------------I--.- --0 <br /> ----------- ---- --------------------------- -----•------------------------------- - ----------------------------------------------------------- <br /> - ------------------------------------------------------- <br /> -- --- <br />! -- ----- --------- ------- <br /> ----------------------------------------------------------------- - - --- --- --- --- - - ------ ----- - -- <br /> Fina! Inspection 6y: --------- --- ----- ------------------ --------------------------------------.Date --7------- --- - --------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 4 <br /> E. H. 9 1-'68 Rev. 5M <br />