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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> - -- ---------- ----'�-------_ ---------- -- - <br /> (Complete in Triplicate) Permit No. -7-/'- ---- <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/LOCATION .----------- . , /f`� !"r rCiry l �_�� r------- C2d CENSUS TRACT ----------------_-------- <br /> Owner's Name s t/-�--------- k '{.�` ' '- ' <br /> -__------------------- - -- -------Phone <br /> Addr - `� � - � <br /> --1---- --- - CIty ---- <br /> Contractor's Name <br /> ----------S.�9 � 0,0UX\_K__.License <br /> # .< i ..l l__ Phone A41 <br /> Installation will serve: Residence ❑Apartment House Ek Commercial ❑Trailer Court ',❑ <br /> 3 <br /> ( Motel ❑Other --------------------------------------------- <br /> Number of living units:_____- Number of bedrooms ____ 1_Garbage Grinder ---_--.--- - Lot Size -__� <br /> Water Supply: Public System and name --------------------------------------------------------------------------------------------------------------Private r <br /> Character of soil to a depth of 3 feet: Sand' Silt Clay Peat Sand Loam Clay Loam <br /> � p ❑ ❑ Y ❑ ❑ Y ❑ Y ❑ � <br /> i Hardpan ❑ Adobe K 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,) V <br /> PACKAGE TREATMENT [ SEPTIC TANK'[ ] F�Size ---------------------------------------------- Liquid Depth -------------------:-__-__• <br /> wr. <br /> Capacity-- "" =----- Type ---------- ----- Material---------------------- No. Compartments -------------••---•-- <br /> D-istancexto:nearest; -well-------------------- ---'_'---�"'---_--Foundation ------------------.--- Prop. Line -:_,--------._.----•-- <br /> LEACHING LINE No. of Li­41nes -____ --___-- Lenth of each line-------- G --_-_ Total Length ------ _____________ <br /> _ g _ <br /> i <br /> 'D' Box ____ ._ Type Filter Mdte_rial __.___ __"'___Depth FilterMaterial ___-_.- --------------------- <br /> �) �S f F <br /> 'Distance`to nearest:'Well'______��_ ____ C � <br /> _--'_ Foundation .___- � -_- Property Line A ------- <br /> SEEPAGE PIT Depth ~�_- Diameter ���_ .�r_ Number,,---_____4.t__._______ Rock Filled Yes No I❑ <br /> - <br /> Water Table Depth ------------ - -------------- -----Rock Size,_,---------------------------- <br /> Distance <br /> ----------------------- --Distance to nearest: Well ----- _:=_r_______________Foondation -' G__f_ Prop: Line __---___ <br /> i REPAIR/ADDITION(Prev. Sanii tion�P.er.Kn.it# -------------------------- Date ---------------------------------- <br /> Septic <br /> -'=4------'--------------------Septic Tank (Specify Requirements) J - ,� ' ---------------------------�=-- --------------------- -------=---- ------ -------- <br /> Disposal Field {Specify Requirements) -----------6�- < -- -• - - --. _ �__.__ __-_L_ -�` 41- --------- <br /> --------------------- <br /> �.�.�. <br /> i <br /> --------------------- <br /> ----- ---------------------------------------- ----------------------------------------------------------------------------------------------- <br /> �._ (Draw existing and required addition on reverse side) <br /> I hereby certify that I have prepared this applications and that the work will be done in accordance with San Joaquin <br /> f <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 /> ----- <br /> Jai - <br /> f <br /> Ay <br /> Y -_ -------------- -Title ----- <br /> B ' <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ------------------------------------------------------ DATE b `---- --- ------ - <br /> BUILDINGPERMIT ISSUED -----------------------------------------------------------------------------------------------DATE - ----------------- =--------------- <br /> ADDITIONAL COMMENTS _ = - <br /> ------- ----- --- ----------------------- ------ -- -------------------------------------------------------------------------------------------------------------- ---------------------- ---------------- <br /> - ---------------------------- -- - --- ----- <br /> Fina[ Inspection by: -. - ---------------------------------------------------------------------------------------------Date --- l-� <br /> G- SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'b8 Rev. 5M <br />