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FOR OFFICE USE: Z <br /> APPLICATION FOR SANITATION PERMIT <br /> --------------- --------------------------------------- <br /> (Complete in Triplicate) Permit No. <br /> --------------------------------------------------------- This Permit Expires 1 Year From Date Issued <br /> Date Issued <br /> Application is hereby made to the San oaquin 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 exis�ggRuleand,Regulations: <br /> JOB ADDRESS/LOCS--� <br /> / f?1 --. I�I � '�' a Acl_ CENSUS TRACT . <br /> Owner's Name ------ ------ ----- ---------- ---�-------- -- Cit Ph ne <br /> Address ---------------- �l --- �-�-------`- ---- -•-- Y -----���___ - <�--- ----------------------- <br /> Contractor's Name ------ -- ------- - - ---- ------ License # _� _ y Phone . <br /> Installation will serve: Residence Apartment House❑ Commercial ❑Trailer Court !❑ <br /> Motel ❑Other -------------------------------------------- <br /> Number of living units:__--( ----- Number of bedrooms ___1�___Garbage Grinder __________ Lot Size _______________________ __________________ <br /> Water Supply: Public System and name ---------------------- -----•-------------------------------------- ----------•-------------------------------Private ) <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam (0 Clay Loam ❑ <br /> Hardpan ❑ Adobe '❑ Fill Material ____________ If yes,type ____________________________ vi <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 /> i i i d. /. <br /> PACKAGE TREATMENT [ ] SEPTIC TANK'Dd Size__6__�1'__!C___A__S__�______________ Liquid Depth _y__�___-.._....__ <br /> _ <br /> Capacity _Ib_Q�_ Type _ _____ Material--- No. Compartments __k --_.........-- <br /> Distance to nearest: Well ______ Cy.�___------------------------Foundation __6�_____________ Prop. Line -_-5-__--.___---.-- <br /> LEACHING LINELines of No. <br /> [ -------9------------ Length of each line-------/£.p------------- Total Length ,_ �'_______________ <br /> 'D' Box ._ __--__ Type Filter Material ----15..k---_-Depth Filter Material ____1 ................................... <br /> /��.� Distance to nearest: Well -------5'_Q_-l------- Foundation ------I_Q------------- Property Line ____._..__...._._ ...... <br /> IT [ Depth -------)_D-------- Dri winter . __X_Lb__. Number _.___-__-___�--i_____-.. Rock Filled Yes [20No 0 a v <br /> Water Table Depth --------------�-o./------ ---------------Rock Size --- -------- <br /> Distance to nearest: Well ___________t—o-_1..................Foundation ___J_Q._.-._.._.. Prop. Line ...6-.-.l <br /> ......... <br /> REPAIR/ADDITION(Prev. Sanitation Permit i# ____________________________________________ Date ----------------------------------) <br /> SepticTank (Specify Requirements) -------- -------------------------------------------------------------------------------------• --------------------------------------- <br /> Disposal Field (Specify Requirements) ---------------------------•--------------------------------------------------------------------------------------------------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> (Draw existing and required addition on reverse side) <br /> I 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 /> "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 become subject to Workman's Compensation laws of California." <br /> Signed _ ___ ___ �; __ f. Owner <br /> ----- - -- --- ---------------------- <br /> BY 'aYZ nL :_ t ---------- Title <br /> •C ------------------------------------ <br /> -- -------------- - --- <br /> -- ------------ - -=- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ---- =l ------------------------------------------------------------------------------------ DATE - 9 7— ------------------- <br /> BUILDING PERMIT ISSUED ------ ----------------- ---------------------------------------------------------------------------------DATE ------------- ----------------- <br /> ADDITIONALCOMMENTS ------- --------------------------------------------------------------------------------------------------------------------------- --------------------- <br /> -------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------- <br /> - ---------------------------------------- <br /> ----------------------------------------------------------------------------------- ------------------------------ <br /> - <br /> Final Inspection by: ` '�q�, ----------------------------------------------------------------- Dte � <br /> ---- a -- ' �7 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />