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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> ------------ --- Permit No.7--1-L-0---7-3 <br /> ---- <br /> (Complete in Triplicate) <br />---------=------------ v\�----------------------- <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/LOCATION .------------4:Y -------------------------CENSUS TRACT ------------- ------------ <br /> Owner's Name -------- --- - -----------------------------------------------f-------------------Phone ------------------------- ---------- <br /> Address --------------------=--------------------------------;---------r <br /> ------- ----------------------------- City ----------------------------- .............................................. <br /> Contractor's Name --- _ '. � .f_ --------=---------------- --------License # --------- ------ Phone ------------------------------ <br /> Installation will serve: Residence ffrApartment House❑ Commercial❑Trailer Court i❑ <br /> Motel ❑Other -------------------------------------------- <br /> Number of living units:--. ------- Number of bedrooms Garbage Grinder .i- _-"--_- Lot Size -------------" _.-.-. _"-_._._.__.__ <br /> Water Supply: Public System and name ----------------------- --------------------------- -----------------------------•-------------- ---Private <br /> Character of soil to a depth of 3 feet: Sand'E] Silt[] CIO E] Peat F1 Sandy Loam ❑ Clay Loam E]Hardpan E] Adobe ill 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.) �1 <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if publfc sewer is available within 200 feet,) <br /> J (�� <br /> PACKAGE TREATMENT [ I SEPTIC TANK f ] Size.. ------------------------------------ Liquid Depth --- ---------------------- <br /> Il <br /> Capacity Apf -,do--- Type <br /> /Material-_--"----_-" ___----_ No. Compartments _............. <br /> Distance to nearest: Well --------------------------- - Foundation /6--------------- Prop. Line <br /> I <br /> LINE [ ] No. of Lines ------ -"-----_-" Length of each line---- <br /> LEACHING � --__ -_ Total Length-f --------------- <br /> 'D' Box .. ----_- Type Filter Material ��v��Depth Filter Material _..� ___________________•._,__-----__ <br /> Distance to nearest: Well ------------------------ Foundation --------------- ------ Property Line ........................ <br /> yNo <br /> �_ <br /> SEEPAGE PIT [ Depth .--2 ----" Diameter ..... Number--------a--------------- Rock Filled Yes <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 /> DisposalField (Specify Requirements) -------------------------------•-------------------------------------------------------------------------- ---------- --------------- <br /> ----- ---------------------- --=----- --------------- - }----------- - - <br /> --------------------------------------- ---------------------------------------------------------------------------------------------------------- ------------------- - <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that 1 s�heave prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, 4tpte Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- <br /> sed agents signature.#ertifies the following: <br /> "I certify that in the performance of the work for which this permit is issued, I shall not employ,pny person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed �lL- ,�1, ---------. Owner <br /> By ------ -- -- - - ---------- ------------------------------------- <br /> Title - <br /> [If er than o ner) <br /> DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY C'�._--�- -------------------- <br /> DATE ----� --/� 7/--------------- <br /> BUILDINGPERMIT ISSUED---- ------------------------------------------------------------------- -------DATE ------------- ---------------- ----------- <br /> ADDITIONALCOMMENTS --'--#------------------- ---------------------------------•---------------------------------------------------------------------=--------=------ ------ <br /> --------------------------------------------- <br /> ---------------- - ------------------------ ------ --- ----------------------- -------- ---- <br /> -- ---- ---------------------- ---------------------------------- <br /> Final <br /> --- --- ----------- <br /> Final Inspection by: - T= - - ----- Date _ ---------� � <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />