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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PEMAFT <br /> -----.-`414a......-- - (Complete in Triplicate) rmrt No. <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/LOCAT ON J10 90-v-.--- - . W 3 c4 7 <br /> 2 r CENSUS TRACT ... ---------------------- <br /> me Name ... .. <br /> --.. ..-.�%�� � - .Phone -- -- - <br /> Address . Cit <br /> --- -- ----- ' ----I.. ---- -- <br /> - <br /> Contractor's Name -- -, License 1� 3�. Phone .--_......................... <br /> - --- ----- -- - - - - �._. <br /> Installation will serve: Residence Apartment Housse ]Commercial OTrailer Court ❑ <br /> Motel E]CKhe 4 <br /> Number of living units:. ---_---- Number of bedrooms ----.-------Garbage Grinder ------ Lot Size ------ <br /> -------------------------------------------- <br /> -.--.�.- <br /> ^ -------- <br /> Water Supply: Public System and name _-------------__-.- Private ln� <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam { lay Loam [[ <br /> Hardpan ❑ Adobe❑ Fill Materia[ ..-__ ---- 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 _.................... <br /> Distance to nearest: Well ----------.-..-_-----_.-..--------Foundation --------------- ------ Prop. Line ---.-.........----.... � <br /> LEACHING LINE [ ] No. of Lines .._.____.---__--- Length of each line . Tota[ Length --_. ............... d <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 <br /> Water Table Depth ------------- -------------------------- ----Rock Size -------------- -- ..... <br /> Distance to nearest: Well _-- --------- -------------------------Foundation ---------- ___ Prop. Line _..__._----..-...- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ---.---- ----------- --- ------ ....___ Date ..................................) <br /> Septic Tank (Specify Requirements) ------------------_--------------- _------U-----_---- <br /> -- -- ...----------------_. <br /> V - - - <br /> ---- <br /> - - _ - --------------- <br /> Disposal Field (Specify Requirements) � -- - _. <br /> ------- -- /---4­4­1---- -- z - - <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 ----------- ------------ ------- - - Owner <br /> By - - --------- -- --- r- - . - - -A- - Title -- A t` Q�'ti. <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY - ------ ------------------- ------ DATE --- 7 y--------------- <br /> BUILDING PERMIT ISSUED ---------------------------- ---------_--- ------------- ---------------DATE ---------- ----- ------------------------ <br /> ADDITIONAL COMMENTS .---- --- ------------------------------- - - -- - - - <br /> - <br /> -------------- ------------ ------------------------------------------------------------------------------------- ------------ ----- - ------------------------------ - ........... <br /> -------------- ------------------------------ ----------------- ----- ----------------- ------- -.... - <br /> ------------------------ ------- -' - - -- <br /> -- - <br /> ----- <br /> Fina Inspection by: ------------------------------------------------------------_ --------Dated - .- - <br /> 4 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />