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FOR OFFICE USE: \`= APPLICATION FOR SANITATION PERMIT <br /> ---------------- ---------------------------------------- <br /> 11 (Complete in Triplicate) Permit No: - -�___' .__ <br /> --------------------------------------------------------- <br /> ' �- <br /> -_-____----_--_--__--_-____----___------------- This Permit Expires 1 Year From Date Issued 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 ON .�,-=--� - � = --'-------------------------CENSUS TRACT ---------------------- <br /> -------------- --- - --- --- <br /> �� +?%� - - 1---- -- - -------------Phone <br /> Owner's Name _ ------- <br /> Address ---------Z =� = - `�' ----- <br /> City <br /> Contractor's Name ? "�-- ---------.License # /- -3YPhone <br /> Installation wiU serve: Residence 06Apartment House❑ Commercial ❑Trailer Court ;❑ <br /> Motel ❑Other -------------------------------------------- <br /> Number of living units:------ --__ Number of bedrooms .7------Garbage Grinder ----- ------ Lot Size ____C '' _- -- -- <br /> Water Supply: Public System and name -------------------------------------------------------------- e <br /> ------Privat ' <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.) C., <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 ._.----------------------- b*Z <br /> Capacity ------ Type -------------------- Material--------- ------------ No. Compartments ----------------•----- 'No <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 ________________________I Foundation __.--------------------- Property Line ........................ <br /> SEEPAGE PIT [ ) Depth -------------------- Diameter ________________ Number -__ .-_--_____ Rock Filled Yes ❑ No SCJ <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 /> Disposj I Field ISpecify Requirements) --- --et-------- ___ ) - _/ -_ ___ ���__ _ _._ ___ _______ _ ________ _ <br /> Wiz= t.: ,-n= - <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 ----------------------------------------- 0wner <br /> ------------------ --- <br /> BY - -�T L� -c- le --- - <br /> ------- ------ ----------- f1 <br /> -------- ----- ---------------------------------- <br /> (If other than owner) <br /> oa FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED ------------ ------------------------------------------ DATE -----------...__. <br /> BUILDING PERMIT ISSUED ------------------- ---------------------------------------------------------------------------------DATE ------------- ---------------------------- <br /> ADDITIONALCOMMENTS ----------------------------------------------------------- ----------------------------------------------------------------------- --------------------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ------------------------------------ --------- ----------------------------------------------------------------------------------------•------------------------------------------------------- <br /> -------------------- -- ------ - ------------=------- <br /> Final Inspection by: � '�V -----------•----------------- --------------------Date- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M � <br />