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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ----------- -------------------------- Permit No. ._7 - � 6 <br /> (Complete in Triplicate) ­­ <br /> ------------------------------ -------------------------- <br /> Date Issued -- 7z <br /> ------------------------- ------------------------------- This Permit Expires 1 Year From 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/LOCATION -- ------------- k-F-=-�----------------- -&k --------------------------- -- ------CENSUS TRACT --- .-- ------•--.- <br /> Owner's Name ---------------- R]s__-Zmni--------------------------------------------------- --------------- ---Phone ---- <br /> Address ---------------------------- >p-4------of_uir--------------------------------------. City -------� ----------•------ - -- --�- -�- -----�----.�---- - - <br /> --••-•- <br /> Contractor's Name --------------------C 4j'Y�4,_�----------------------------------------=--------License # ---------.-------------- Phone ------------------- <br /> Installation will serve: Residence ❑ Apartment House❑ Commercial []Trailer Court ;❑ <br /> Motel ❑ Other --- ------------------------------ <br /> Number of living units------J----- Number of bedrooms ----a----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 ❑ Clay Loam F] <br /> Hardpan ❑ Adobe ill 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.) f <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 ( ] 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 --_--.-._-__________-___ �T <br /> SEEPAGE PIT [ ] Depth _.------------------ Diameter ________________ Number ---------------------------- Rock Filled Yes ❑ No i❑ <br /> w Water Table Depth ------------------------------------------------Rock Size ---- --------------------------- <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ------------_-------- <br /> `7 <br /> REPAIR/ADDITION(Prev. Sanitation Permit# --------------------------------------------- Date ---__________.________-___--______) <br /> Septic Tank (Specify Requirements) ---------- = 3 --------------- -------••-- <br /> Disposal Field {Specify Requirements) ------- ., <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, 1 shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed - --------------------------------------------------------------•- Owner <br /> BY -------------------- ------------------------ Title t� f� -- <br /> ----------------------- <br /> ---- - <br /> {If other than owner) <br /> FOR DEPART) SIT SE LY <br /> APPLICATION ACCEPTED BY -------------------------------- -------------- = - DATE <br /> BUILDING PERMIT ISSUED ----- - ------------------ ------ --- ------. _--DATE ----- <br /> ` <br /> ADDITIONALCOMMENTS -------------------------------- ------------ ------------------ -------------------------------------------------- ----------------------------------- <br /> -------------------- <br /> ------ ------------------------------•------------------------------------- ---------------------------------------- <br /> Final Inspection by Date ' <br /> SAN JOAQUIN LOCAL HEA DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />