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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> - ----------- -------- -�����.�� <br /> (Complete in Triplicate) Permit No. <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 No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOC N GU ul--� --1'-``-- - ----------- ----e '_w }.--S� `- Gc--CENSU'S TRACT -------------------------- <br /> Owner's Name ------- --------Cg--------------------------------------------- -------Phone ------ <br /> Address ------------------- -- �p l� � � City C� <br /> • - <br /> - ------------------------------------------ <br /> Contractor's Name - -----X -_---.License # _/71,3�__ Phone ------------------•--......... <br /> Installation will server Residence E]Apartment House❑ Commercial;❑Trailer Court ❑ <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'E] Silt Clay Peat El Sandy Loam Clay-Loam,11 <br /> Hardpan W Adobe'❑ Fill Material --_- -. if yes,type ---------------------------- <br /> (Plot <br /> ----------------- ---(Plot plan, showing size of lot, location of system in relation to welds, 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------------------------------------------------ Liquid Depth ---------------------.__-. <br /> Capacity -------------------- Type ----------- ------ Material-----------.----------- No. Compartments ------ --- <br /> Distance to nearest: Well --------------------- --------------Foundation ---------------------- Prop. Line --.--------.---.------ <br /> LEACHING LINE [ 7 No. of Lines ------------------------ Length of each line --------------------------- Total Length ------------ <br /> --------------- <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 i❑ <br /> Water Table Depth ------------------------------------------------Rock Size ---------------- <br /> Distance to nearest: Well ----------------------------------------Foundation ---------------.---- Prop.{Line -----.--------._------ J. <br /> REPAIR/ADDITION(Prev. Sanitation Permit#' -------------------------------------------- Date -------------------------..-------} <br /> SepticTank (Specify Requirements) -------------------------------------------------------------------------------------------:-------------­_­1---------------------------- <br /> Disposal <br /> - 1---------------,----------- <br /> Disposal Field (Specify Requirements) ----- __`-.------- ----------7.3- X 2 S <br /> ---- -------A`J----------------- <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 become subject to Workman's Compensation laws of California." <br /> Signed ------------------------ ------ ---- ---- ------------------ Owner <br /> . <br /> BY ------------------------------- -- Title --------------------------------------- { <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -- _ -__-- _-'-- __-- =----------------- ----------- DATE /"1 p. ". -------__ <br /> --------------------------------- <br /> BUILDING PERMIT ISSUED ------------------------- ------------ <br /> --------------------------------------------------------------------------------DATE -. --- ---- -- - <br /> -------------------- <br /> ADDITIONALCOMMENTS ----------------------------------------------------------------------------------------------------- ----------------------------=--------------- ----------- <br /> - ------ ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> - -------------- ------------------------------------------------------------------------------------------------------------------------------ <br /> ----------------------------------- ------------/_ ------- <br /> --------- <br /> --- = <br /> Final Inspection by: Date <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT ° <br /> E. H. 9 1-'68 Rev. 5M• <br />