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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) � <br /> Permit No. __-.-"_"_/-" <br /> ---------------------------------___-----_--_---" k This Permit Expires 1 Year From Date Issued <br /> 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 ismadeiin� compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION �- -------------- -------------------------------CENSUS TRACT -----------------•-------- <br /> Owner's Name "* <br /> --- - --------------------------------------------------------- -------------------Phone ------ <br /> r <br /> Address aY --r- <br /> ----------- - ------------------------------------------------- City ------------------ --------------------------------------------------•---••- <br /> Contractor's Name ----C�, <br /> .--T-3---------- l <br /> --------------------------- License'# -��.��-- - Phone ----------- - ---------- - --- K <br /> Installation will serve: Residence fl)-Apartment House,[] Commercial :❑Trailer Court !❑ <br /> Motel ❑Other <br /> Number of living units------ ---- Number of bedrooms -2--------Garbage Grinder""._. -- Lot Size _0--------- <br /> - ------------- <br /> Water Supply: Public System and name ----------------- ----------------------- --------------------------------------------------------------------Private F19__1. J. <br /> S <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay--El Peat ❑ Sandy Loam ❑ Clay Loam M 1 <br /> Hardpan ❑ Adobe [Fill Material ------------ If yes, <br /> (Plot plan, showing size of lot, location of system 1n relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: <br /> (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) `h , <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size.---------------------------------------------- Liquid Depth -----------_----_---.--- <br /> Capacity ------------- ---•-- Type -------------------- Material------------------4--- No. Compartments -----------------: V} ; <br /> Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ------------.."_---_-- <br /> LEACHING LINT= -[ ] No. of Lines ------------------------ Length of each line----------------------------- Total Length ----------------------------- <br /> 'D' <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 'E] No 1❑ <br /> Water Table Depth ------------------------------------------------Rock Size ------------------ --------•---- <br /> Distance to nearest: Well --------------------------- ------Foundation -------------------- Prop. Line -------------_-----. <br /> REPAIR./ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ------_---------------------------) <br /> Septic Tank (Specify Requirements) -------- -------------------------------------------------- <br /> Disposal <br /> ---------------------------- -----------------Disposal Field (Specify Requirements) - "--------C Are-- C t <br /> ------------------------------------------------------------ ------------------------------------------------------------------------------------ -------------------- ---------------------------------- <br /> ------------------------ ------------------------ --------------------------------------------- ------------------------------- ; <br /> (Draw existing and required addition on reverse side) <br /> ication and that the work will be done in accordance with San Joaquin <br /> ! hereby certify that I have prepared this applk <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 4his permit is issued, J 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 . - ............. <br /> - -------- ---- --- ----------------- ------------------ Title ---------------------- ----------------- <br /> (If other than ned I' <br /> FOR DEPMTAAENT USE ONLY � <br /> APPLICATION ACCEPTED BY -- , <br /> ------ u . .. <br /> ADIDI IONA PERMIT OMM NTSD1 "� `s - -DATE <br /> -------------------- ------------------------- --------------- --- ------ ---- ---- --- ------ - ---------- _------------------------------ --------- - - <br /> ------------------------------------------------------------------------------- ------------------------------------------------------------------------------- --------------------------- ----- <br /> -- ----- ----- - <br /> ------ <br /> ------------------------------------------------------------------------------- ------------- <br /> nalIns ectionbY° - -------------------------- -=------- <br /> Fi - --- -Date - - ----- - -- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> - <br /> E. H. 9 1-'68 Rev. 5M <br />