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FOR OFFICE USE- <br /> APPLICATION APPLICATION FOR SANITATION PERMIT <br /> -------- %y yG� <br /> �3D ]Complete in Triplicate) Permit No_ _____________________ <br /> ,- j <br /> ___________ ___________________________________________ 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 ismademade in compliance with CountyOrdinanceNo. 549 and existing Rules and Regulations: <br /> 1 Lqy(� c � "`^' �a---------------CENSUS TRACT -------------- ----------- <br /> JOB ADDRESS/LOCA N _ <br /> Owner's Name j::?- i I 1 - J r� `� ---------------------------------------------------------- Phone_c c]--`--Q-6-- <br /> Address / r/ � � ------12^----. CityrP �---- ------------- ------------------••- <br /> Contractor's Name ___-__-�-,__� ----CLicense -_ Phone _._��3_-'�' <br /> Installation will serve: Residence [�K Apartment House❑ Commercial❑Trailer Court ;❑ <br /> i Motel ❑ Other -------------------------------------------- <br /> Number of living units:-__ ___ Number of bedrooms s.3______Garbage Grinder ------------ Lot Size'-GA ........... <br /> Water Supply: Public System and name ------ ------ •-----------------------------------------------------------------------------•---.-_--.Private <br /> Character of soil to a depth of 3 feet: Sand Xr Silt❑ Clay ❑ Peat ❑ Sandy Loam J9 Clay Loam <br /> Hardpan ❑ Adobe '❑ Fill Material ------------ If yes, type ---------------------------- <br /> (P lot <br /> ___________________________(Plot plan, showing size ofJot, 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,) `\ <br /> PACKAGE TREATMENT { ] SEPTIC TANK`[ ] Size ,___________ 'Y � ________ Liquid Depth _--�__________,____ <br /> S' / <br /> I Capacity, -_ Type __�� ` - _ Materi i_Y�r��_ ._____� No. Compartments _- <br /> ��� / <br /> Distance to nearest:' Well ----------------------Foundation _/0" <br /> CU_ _______..._ Prop. Line --------.,_.____ , <br /> [ ] ---- ------------ Length of each line----- -__------------ <br /> LEACHING LINE No. of Lines Total Length d----------------- <br /> 'D' <br /> •------____--'D' Box Type Filter Material ____Depth Filter Material -------------------------------------- <br /> rd <br /> Distance to nearest: Well ___,�r�________ Foundation �_�______________ Property p ty Line _____________ <br /> i <br /> SEEPAGE PIT [ ] Depth ____________________ Diameter ________________ Number ---------------------------- Rock Filled Yes ❑ No C] <br /> Water Table Depth ------------------------------------------------Rock Size-------------------------- <br /> Distance to nearest: Well ----------------------------------------Foundation --------------------- Prop. Line ...................... <br /> REPAIRJADDITION(Prey. Sanitation Permit# --------_----------------------------------- Date ________________________-_________j <br /> SepticTank {Specify Requirements) ------------------------------------------------------------------------------------------------------------ -------------------- ------ <br /> Y <br /> DisposalField (Specify Requirements) ---------------- --•----------•--------•--------------------------------------------------------------------------------------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> E a <br /> -------------------------------------------- --- ------`---------------------- ------------ ------------ --- ------------------------------------------------------------------- <br /> (Draw existingand 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::.x� <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 /> t <br /> as to become subject to Wor an's Compensation laws of California." <br />{ Signed - - ----- -------- ----- Owner <br /> r By ----- l � � - ---------------- Title --------- ----------- --- ---- --- ----------- ------------ <br /> ------------ <br /> (If other than owner) <br /> I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -------------------------------------------------------------------------. DATE <br /> BUILDING PERMIT ISSUED --- F---------------------------------------- ---------------------------------------------------DATE ------------------------------------------- <br /> ADDITIONALCOMMENTS ------------- -- ---------------------------------------------=------------------------------------------------------------------------------------ ---------- <br /> 4 <br /> = ---------I------------------------------------------------------------- ------------------------------------------------------------------- <br /> ' ----------------------- <br /> ------------------------------------------------------------------------------------------ --------{ p -------------- <br /> Final Inspection by:: --- ---- -- -------- - Date - --- --1 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />