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FOR OFFICE USE: <br /> .- APPLICATION FOR SANITATION PERMIT <br /> -------------------------------------------------------- a `' � � <br /> (Complete in Triplicate) Permit No. _� <br /> -------------------------------------------- <br /> R Date Issued -4-7-3 <br /> ---------------------____--____-______________.___________________-___- This Permit Expires 1 'ear From 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 is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION-"_--51_fi � 3 <br /> ------ ----------- <br /> --- � _,=- <br /> Owner's Name ----- ------- ------------Phone ------------------------------------ <br /> Address --- s '- p}' f - "` City _Q --------------------------------------------•------ <br /> Contractor's Name -- _.z ------------------------------------ ---------------------------License # ------------------------ Phone ------------------------------ <br /> Installation will serve: Residence Apartment House❑ Commercial ❑Trailer Court ;❑ <br /> Motel ❑Other _________________________ <br /> Number of living units:-----D------ Number of bedrooms __ -_____Garbage Grinder ------------ Lot Size -`____----___---------------- <br /> Water Supply: Public System and name ------------------------------------------------------- ------------------------------------------------------PrivateA <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,) W <br /> PACKAGE TREATMENT [ ] SEPTIC TANK:N Size-----/.=Z-------A_' _ ------------------- Liquid Depth ._°~--_-__.__-____-_-• <br /> Capacity rR _ ""'-??-------- Type ;' --- -= --- Material__ ------------ No. Compartments '................. <br /> Distance to nearest: Well 0.0-___________________Foundation ___ --------------- Prop. Line __ ......... <br /> LEACHING LINE [ No. of Lines ----5;� _____________ Length of each line--_-_/1'��______.___- Total Length ' .------------ <br /> D' Sox Filter Material _____._Depth Filter Material ___`_--------- <br /> Distance to nearest: Well -_----------- Foundation ------------------------ Property Line 'Z7.,_.....- <br /> SEEPAGE PIT ,[.�-] Depth _ ;;4__.-____ Diameter _ ` __ Number -_____,m-_______________ Rock Filled Yes. ] No Cr <br /> Water Table Depth ----f___"r--�-----------------------------------Rock Size --- ---.--------- <br /> 1-1 <br /> Distance to nearest: Well _a- ----------------------------Foundation __'--------- Prop. Line ^-: -_.-_--_-_--__-- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------•------------------------------------ Date --------------------_____-__-_.__.) <br /> SepticTank (Specify Requirements) ------------------------------------------------------------------------------------------------------------------------------------------ <br /> Disposal Field (Specify Requirements) _ <br /> ------------------------------------------------------------------------------------- <br /> ________________________________ _______________ <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, 1 shall not employ any person in such manner <br /> as to become subject t Workman's ompensa7inlaws of California." <br /> Signed 1V Q/ �,,.. Owner <br /> - -- - - <br /> By ---------- ------------------------------------------------------------------- Title ------------------------------------------------- ----------- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY �r"r_, DATE _'__�` <br /> ----- - ----- - ------ --------- --------- <br /> BUILDING PERMIT ISSUED - ----- ---- -- --------------------------------­­----------------------------- <br /> ------------ ---------------------------- <br /> ADDITIONALCOMMENTS -----------------------------------------------------------------•---- ------------------------------ --------=------- ---------- -------- <br /> - -- -- ---•-- <br /> -- ----- - <br /> Final Inspection by: _. w _ ---- - - -- - e--- -- ---- -. . -Date ��2 --- - - <br /> f <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />