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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) it No. <br /> ----- - ---- - SCANNIf�' J/ <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/LOCATION _� _/..:�` .. �-f!- _�� �/7-(�-----_l / - /JCENSUS TRACT <br /> Owner's Name ._� � - one <br /> Address ----_-S --- ------------------------------------------ -- ------------------ Ci <br /> Contractor's Name ..__---- - :Q1(4�? 1C�_� _--- ----- --- __License #/W,�k�. <br /> Installation will serve: Residence Apartment House❑ Commercial ❑Trailer Court ❑ <br /> Motel ❑ Other <br /> Number of living units:..-./.--- Number of bedrooms _;z.------Garbage Grinder Lot Size <br /> Water Supply: Public System and name --------------------------------__ -----------------------------------------------------------------Private <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt p Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan 5§ Adobe ❑ Fill Material - If 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 �4 Size.����X_v'��..�._._._ _ .._ Liquid Depth __..._-.__.... <br /> Capacity /-,c_'QQ._ Type�L9/e ! .-- Material --- No. Compartments -Z__-_---..._- O <br /> Distance to nearest: Well ----- --------------------Foundation __/G_----------- Prop. Line <br /> LEACHING LINE LINE No. of Lines _-3__ -----__. Length of each line..._ . ...... ----- Total Length?� ___a- �!�---_.-_-__ <br /> 'D' Box 11�. Z- Type Filter Material/ -Depth Filter Material XF ._ ---.____---------------- -V <br /> Distance/to nearest: Well _,' 00------ -_ Foundation _-Lt'_ __-.-... Property Line .Ll.. -._._...... <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) - ------------- ....... - ---------------------------------- <br /> Disposal Field (Specify Requirements) -------- --------------- - -------- --------------------------- - - --- <br /> ----------- ------------------ ------------ ------------- ----------- ----------------- ------- - ------------------------------------- ---•------------ <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 Camp nsation laws of California." <br /> Signed .- --------- ----- - ------- Owner <br /> ---------- ---- ----- --- --- -- <br /> By - _- - --- ---------._ . _. Title -C�I�Y�jt -- <br /> (If of than owner) <br /> _ 101 FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY - --- ---------------------------------------------------.__-- DATE _ :f Q"�-9 <br /> BUILDING PERMIT ISSUED -- .. . ..... ---- ----- ------- - ---------------- DATE - ------------------------ --- --- <br /> IT NAL COMMENTS --- ---------------------------- <br /> ------------ - ------- --------- - --- - . - - --- --------- -- - - <br /> ----------------------------------------------------------------------------------------------------------------------- <br /> ------------------------- - -------- <br /> -- --------------- - - ------- -------- ----------------- - ------ -- - --------------- ------------------- - <br /> - --------------------- -------- --------- fy <br /> Final Inspection by: - --------- "I----- ------------ ---------Date Z � - - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />