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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> - Permit Ngo/�-� <br /> - -�`------------------- (Complete in Triplicate) ------ <br /> This Permit Expires 1 Year From Date Issued <br /> Date Issued - --------------- <br /> Application <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 __-_+�___ �-- t +�d---------------------------------- <br /> p ,y -------------- CENSUS TRACT �S-'f/ <br /> Owner's Name --�r�-?� Phone <br /> Address --- -----Xr, _V---------------------------------------------- City `"0---------------------------------------------------- <br /> f'- <br /> Contractor sName ----.:_-z==r:�=c��...-----,a -`-- -�-------------------------------------------License # ----------------------- Phone ------------------•---•-•----- <br /> Installation will serve: Residence ff Apartment House-❑ Commercial ❑Trailer Court ;❑ <br /> Motel ❑Other -------------------------------------------- <br /> Number of living units:------------ Number of bedrooms _______-.---Garbage Grinder ------------ Lot Size st ""y ! -------------------- ----- <br /> Water Supply: Public System and name ---------------------------------------------•---------- -------------------------------------------------------Private <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam;Q9 Clay Loam ❑ <br /> Hardpan ❑ Adobe ❑ Fill Material ------------ If yes,type ___________________ ------- <br /> (Plot <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 Q ] Size___________________________-___-__------------- Liquid Depth __.-____-...___-......... <br /> all <br /> Capacity __---------------- Type -------------------- Material=--------------------- No. Compartments ...................... <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 -------------------------------------------- A, <br /> Distance to nearest: Well ________________________ Foundation ------------------------ Property Line ___--__-_.__.-___-.--•-- <br /> SEEPAGE PIT [ ] 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) ------------ -„----„-,r--/------- ---------------------- ----------------------------- ------------------------------------------ ----------_-- <br /> Disposal Field (Specify Requirements) -__---� 044, - ,-------- ­000 ��?� ------#a- 'y'�-•--------------- <br /> ------------------------ ' ------4- <br /> --- 4------YP'-' '_P-r_' . - r x ,-- ----------- ------- --------------------------------------------------------------- <br /> ---------- ----- - ------ --I -------------------------------------------------------------------------------------- <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 /> "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 becom <br /> e to Workman's Compensation laws of California.” <br /> Signed --- ----------------------------------------------------- Owner <br /> By --------------------- - ------------------------------------------------------------- Title ------------------------------------------------------------------------ <br /> (If other tha owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ---------------------------------- ---------------------. DATE `3 ------------------- <br /> BUILDING PERMIT ISSUED -------------------------- ------------------------------------------------- ----------------------------DATE ------------------------------------------- <br /> ADDITIONALCOMMENTS ---------------------------------------------- --------------------------------------------------------------•---.•------------------------------ <br /> ------------- ------------------------------------------------------------------------------------------------------------------------------------------------------ -------- ---- - ------- <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -- ---------- <br /> a <br /> ------ ------------------------- :'�-- '`�----- -=--- -- ----- -- '---------- - ----' - -- - ---' --- - ----- - -- -.'_'_--- <br /> Final Inspection by:---- <br /> y: -_ Date " a' - - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />