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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT �,r �,r <br /> ------------- ---------------------- -)Y' (Complete in Triplicate) Permit No. --- - ----- - <br /> ---------=----------------------------------------------- <br /> This Permit Expires 1 Year From Date Issued Date Issued�l <br /> _ _ _ <br /> _______________ _-_. _ _--.--_-. <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 rdinance No. U9 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATI - ?�±^� __ ,.__ _ _'7�-_. ,,_ __._�r _A- _CENSUS TRACT __________________________ <br /> } - <br /> Owner's Name ---- - �- - <br /> Address --- // --- -- -------------------------------------- <br /> + ��F r i T <br /> CityContractor's Name -_ ---- ------ .--�- --- ._ _._---_-_----.License # AF41FPhone ------------------------------ <br /> Installation will serve: Residence F1 Apartment House❑ Co mercial 7ji�! <br /> urt <br /> Motel ❑Other -----------------'' <br /> Number of living units:--------- Number of bedrooms _-___-.._--Garbage Grinder _________ Lot Size --- :Y_W___-_______________ _______ <br /> Water Supply: Public System and name ----------------------_------------------------------------------------ _Private <br /> Character of soil to a depth of 3 feet: Sand❑ 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---------------------- No. Compartments ...................... 1 <br /> Distance to nearest: Well -__________________________________Foundation ---------------------- Prop. Line __--___-_.._-._.-_---- <br /> LEACHING LINE [ ] No. of Lines ________________________ Length of each line---------------------------- Total Length ---------.-.,__------__.---- <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 © 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 /> Disposal' Field (Specify Requirements) .._ 4 7-...' __ _ . . -� �-- <br /> ----------------- --------------------------------------------------------------------------------------------------------------------------------------------------------------` <br /> ------------------------ ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> (Draw existing and 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: <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 /> BY ---------------------- � ✓f-.4- , Title <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY l <br /> APPLICATION ACCEPTED BY -----------------=------------------------------------------- -. DATE'` ------ ----------- <br /> BUILDING PERMIT ISSUED ------------------------------------ -----------------------•--------------DATE --------------------- --------------------- <br /> ADDITIONALCOMMENTS ----------------------------------------------------- ----------------------------------------------------------------------------=----------------------- <br /> ------------- -------------------------------------------------------------------------------------------------------------------------------------------------------- ----------------------------------- <br /> --------------------------------------------------------------- ------ -------------------------------------------------------------------------------------------------------------------- --- <br /> ---------------------------- - <br /> Final Inspection by: P%� --------------------------------••-------- ----------------------------- Date <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />