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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ------------------------------------ (Complete in Triplicate) <br /> Permit No. <br /> -------- ------- ----------------------- <br /> Date Issued /�--�-- <br /> _-__-_--__-__--_-----_---____---_-------- This Permit Expires 1 Year 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/LOC N _ _ <br /> -__-__ Vi' " `"a----CENSUS TRACT ----------__ .------ ---. <br /> �� j -------Phone ------------------------------------ <br /> Owner's Nam + ------ e - ------ -- -- <br /> Address - a u�' 1 - - City - - -------------------------- ---------- <br /> Contractor's Name ------- �- G _ �✓l�- 1� -.License #/0. Phone <br /> Installation will serve: Residence E�tApartment House f❑ Commercial ❑Trailer Court ;❑ <br /> Motel ❑Other -----_--,--/--'------------------------------- <br /> Number of living units:------ Number of bedrooms .:,d__......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 lay 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 ---------............ <br /> Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ---------------------- <br /> LEACHING <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 i❑ <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) ------------------ ---------------------------------------------------- ------ ---- -------------------------------- <br /> L-�r-�1"---I <br /> Ae <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 /> "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 to Workman's pensation laws of California." <br /> Signed ----- - r-15VV P <br /> -------- ---------------------- ----- <br /> BY ------------ titlep Y'°- �c'stj_ <br /> ------------------ <br /> -------------- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY j <br /> APPLICATION ACCEPTED BY ------- - ---- ----------------------------------------------------------------. DATE,t. -/ ------------------------- <br /> BUILDING PERMIT ISSUED ----------------------------------------------------------------------------------------------------------DATE ---- ---------------------------- --------- <br /> ADDITIONALCOMMENTS ----------------------------------- ------------------------ -------------------------------------------------------------------------------------------- <br /> ------------------------------- -------------- ---------------------------------------------------------------- ------------------------------------------------------------ -------------- <br /> -------------------------------- <br /> --- - - -- - ------------- <br /> -----� ------------------------------------------------------------------------- <br /> Final Inspection bY: ------- ----------------------------------- -----------Dated ------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />