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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> --------------------- - , Permit No. <br /> (Complete in Triplicate) <br /> ---'- -------'- - �.. <br /> -------'-----'---------- G <br /> Date Issued .1 . :�--- 7 <br /> _____________________ ---------------------------------- This Permit Expires I Year From Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and instal-1 the work herein <br /> described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LO TION - ..... .......... ' --------------------- ----CENSUS `BRACT ------------ ----------- <br /> Owner's Name ----- -- - ------- -------- ------ ------ --- ------ - - - ---- --- -4-e-!::-e------ --------- Phone --- <br /> ----------- ----- <br /> 1 <br /> Address --h^f `� - �`7 �'�c"' '"'�`"p- City - ------------ ---- -'° <br /> Contractor's Name - f------ ------ ----------License # _,Y' T��hone <br /> Installation will serve: Residence �rtment House,❑ Commercial [-]Trailer Court ;❑ <br /> / Motel F-1Other ----------------------------------------- <br /> Number of living units:___I-_____ Number of bedrooms _3-----Garbage Grinder ------------ Lot Size --.•___-- <br /> Water Supply: Public System and name ---------------------------------_------------------------------------------------------------ --- ------Private <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Gay ❑ Peat❑ Sandy LoamClay 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 f ] Size---------_____---------------------------------- Liquid Depth __--______--_.----___•-_- <br /> Capacity ------------------ Type -------------------- Material---------------------- No. Compartments ...................... �l <br /> Distance to nearest: Well ____________________________________Foundation ,----------------------- Prop. Line ...................... <br /> LEACHING LINE [ ] No. of Lines ------------------------ Length of each line_____________ Total Length ------------_--------------- <br /> 'D' <br /> ___________'D' Box ------------ Type Filter Material ____________________Depth Filter Material -____-_--_-__-_--_-_.___-___-•.-------.._-.- <br /> Distance to nearest: Well ------------------------ Foundation __-.-------------------- Property Line ---____--.--..•-_..__--- <br /> SEEPAGE PIT [ j Depth -------------------- Diameter ---------------- Number ----___----------.------ Rock Filled Yes ❑ No 0 <br /> WaterTable 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) _ _045 - - --- -------------- <br /> -------- � ---------- - -=------� LXZ_S - <br /> '"------ 46----- __ --i ---------- ----------- ----------------------------------- --------- <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 s Iec o Workman's Compensation laws of California." <br /> Signed --------- Owner <br /> BY -- - `` g�'� ----- Title .- ------------------------------------------------------------ <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY - ----_ DATE / 7--6--X----------- <br /> ------------------------------------------------------ <br /> BUILDING PERMIT ISSUED . -------------------------- <br /> --------------------------------------DATE ------------------------------------------- <br /> ADDITIONALCOMMENTS ------------------------------------------------------------------------------------------------------------------- ------------------------ ----------------- <br /> -----------------­----------------------------- <br /> --------------------------------'-'--------------------------- ------------------------------------------------------------------------'------------------------------------------------------------------------------ <br /> ----------------------- -- ------ - •-------- - --------- - t�1 -------- ---- <br /> Final Inspection by: ---- -- ------------------------- ------•------------------------------------- Date/A__ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />