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FOR OFFICE USE: f, - 16— <br /> APPLICATION <br /> 6—APPLICATION FOR SANITATION PERMIT <br /> ------------------------------------------- ------------- Permit No. _ <br /> (Complete in Triplicate) <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 per 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 /> JOBADDRESS/LOCATION .-------J-------------------------------------------------------------------------- ------ ------CENSUS TRACT --------------_---_---- <br /> Owner's Na/mem/ �z..: !�- Y�_1 _,<'� tk�? 1�+� -------------------------------- ------- -----------Phone 017._! 1012..... <br /> Address -----b-"12=----- -r ---•---•-- <br /> Z--�-�-t'-/°-��------�-�--------------------_,--. City �-�'`Y-tfV= --�'4!�4--------------------------------- <br /> Contractor's Name -_--61(]%D�rZ�-.----&W-t2 -------------------------_-_.License Phone <br /> Installation will serve: Residence (Apartment House❑ Commercial ❑Trailer Court 10 <br /> Motel ❑Other ------------------------------------------ <br /> Number of living units:------------ Number of bedrooms _--___-_-__Garbage Grinder ------------ Lot Size __7__$7.............. <br /> Water Supply: Public System and name --------------------------------------------------------------------------------------------------------------Private (K <br /> Character of soil to a depth of 3 feet: Sand'g Silt❑ 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,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size-_ --------------------------- --------------- Liquid Depth -___-----_----.-.-.__--. <br /> Capacity -------------------- Type ------------------- Material---------------------- N . Compartments ---------------------- r'1 <br /> 037 <br /> Distance to nearest: Well ------------------- ----------------Foundation ---------- ----------- Prop. Line ...................... n <br /> LEACHING LINE [ ] No. of Lines ------------------------ Length of each line---------------------------- Total Length -------------------------_- <br /> 'D' Box --.---_---- Type Filter Material __ ________________Depth Filter Mate iai __--_________.____--_________-_-.---.._---- <br /> Distance to nearest: Well -------------------- -- Foundation ----------------------- Property Line ........................ <br /> SEEPAGE PIT [ ] Depth ----..----_---_---_ Diameter ___________ ___ Number --------- ----------------- Rock Filled Yes ❑ No <br /> Water Table Depth ------------------ ------------------Rock Size --------------- ---------------- <br /> Distance to nearest: Well ____________________ __________________Foundation ----------- _______ Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# --------------------------- -- ------------ Date ........................ --------) <br /> SepticTank (Specify Requirements) --------- -------------------------------------------------------------------------------•--- -----------------.----------------•----------- <br /> DisposalField (Specify Requirements ----- ------------------•-------------------------------------- --------------;--------------------------------------------- <br /> dd------/-exop------? 24��_e" ---------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> (Draw existing and required addition on reverse side) <br /> 1 hereby certify that 1 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, I 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 /> BY -= Title <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -------- _ __ ._ ,_ ------------------------------------------------------- DATE -------- -_`_ 2�_-_____. <br /> BUILDINGPERMIT ISSUED ----------------------------------------------------------------------------------------------------------DATE ------------------------------------------- <br /> ADDITIONALCOMMENTS ------------- ---------------------------------------------------------------- --------------------------------------------------------------------------- <br /> --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ....... <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> -? ----------- - <br /> Final Inspection b = _--------------------------------------------- ---- -------------- ----Date --- ----------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />