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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION'PERMIT <br /> ----------------------------- ------- a a/ <br /> } (Complete in Triplicate) Permit No: Wil__/__-_._____. <br /> ". -: -Date Issued <br />-------.--- This Permit Expires 1 Year Froin Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a per to construct and install the work herein r <br /> described. This'application is madein compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCA? N,,. I� , = y' --------------------------------------CENSUS TRACT --------- <br /> S . _ _ _ _-__�_r i <br /> Owner's Name ------ t----------- Phone. - - ------ � -- <br /> �� , ---- ' <br /> Address - = City ---------- <br /> ------ <br /> Contractor's Name =-------License # sP��73 Phone -��4`3'�,•,Er .t 1 t k� <br /> Installation will serve: Residence E5<, partment House❑ Commercial ❑Trailer Court ',❑ , <br /> Motel ❑ Other -------------------------------------------- c <br /> Number of living units:_______ Number. bedrooms _______Garbage Grinder ------------ Lot Size --- $.XZ 4-------- <br /> Water Supply: Public System and name -`----------------- ---- _. ------------------------- -•--------------- - Private ❑ <br /> yr r I , <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt 0. E Clay ❑ Peat❑ Sandy Loam -❑ Clay,Loam ❑ <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,) `t <br /> PACKAGE TREATMENT [ ] SEPTIC TANK:[ ] Size----------------------------------- ------ ---- Liquid Depth ----------------------_-- <br /> Capacity <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 -------------------- pt Filter Material <br /> 'tenal -------'- ---------- ----------- ........... <br /> Distance to nearest: Well __,______________________ Foundation ---------n Property Line_ ._-_._.._________-._._-_ <br /> SEEPAGE PIT [ ] Depth ------- ----------- Diameter _______________ Number -_--------------------I----- Rock filled Yes ❑ No <br /> Water Table Depth'"'"""-__'- . �' _ <br /> -----------------------------=--- =--Rack Size---------------- --------------- <br /> A o <br /> Distance to:nearest: Well ----------------------------------------Foundation ------------ 'Poop. Line ...................... <br /> Y <br /> REPAIR/ADDITION(Prev.�Sanitation Permit# ____________________________________________ Date ----------------- <br /> -- --- <br /> �: -/ <br /> Septic Tank {Specify Requirements) ----------------✓----------- = --- - ;- ' <br /> Disposal Field (Specify Requirements] ___.. --�l�-_ _ ____ _ _ __._ f _- __ :_i___ ------ _ ------------ # <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 a cordanie_with Son Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home ownef or licen- <br /> sed agents signature certifies the following: I <br /> "1 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 bec a su lett tq W rkma 'a Compensati. aws of California." <br /> Signed ------------------ - ----- ---------- -- ------------------------------- Owner. <br /> By ---------- -- - - -----=-------------------------------- -Title =----------------- --- <br /> (If other than own <br /> FOR .DEPARTMENT USE ONLY �. <br /> APPLICATION"ACCEPTED 'BY - INNIYJ-- ------- -- ----------------------------------- '---_-------------------------------------- DATE --- ------------------- <br /> BUILDING PERMIT ISSUED --- -----------------------------------------------------_�----- -------------------------------DATE <br /> ADDITIONAL COMMENTS -____--- ----------------------------------------- "4 <br /> --------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------- <br /> ----- --- ----------- ----------------------------------- ---------------------------------------------------------------------- -=---- <br /> ------ ---- - <br /> Final Inspection by: '�-- --------- -----------------------------=- ------------- -------------------------.Date -- }� <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />