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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit No_ _____________________ <br />-_____--___-.--_-______-_-___-_-___-_-----_----- <br /> This Permit Expires 1 Year From Date Issued <br /> 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 .--- - ----,--��-°-- ------- --------------------------------CENSUS TRACT -------------------------- <br /> Owner's Name -------):-�--_ hel--]-------- V ------------------------------------------ <br /> _ Phone <br /> Address ---- -------- -cam-icr-�-------------------= --. City ------ � � °------------------------------ <br /> Contractor's Name d�-___ -------f&-,A_K----License # _ _ +_ 9 f-__- Phone w-—3:72 q.g.. <br /> Installation will serve: Residence X Apartment House❑ Commercial ❑Trailer Court <br /> Motel ❑Other------------------------------------------- <br /> Number of living units:---I-------- Number of bedrooms ____`_____Garbage Grinder .----------- Lot Size ----- e'_`_ _a-Q ...... <br /> Water Supply: Public System and name --------------------------------------------- __ Private ❑ <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe X 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 [ ] SH TLC TANK OQ Size_______o?_.._ ___ ��%_________ Liquid Depth ___,/ _____________ <br /> Capacityl_/Z hype -_--- -4----- Material CO-YI-0--ireNo. Compartments _-_-.4Z............. W <br /> ,r -4'., J <br /> Distance to nearest: Well ____________________________________Foundation -----1!�_____--- Prop. Line ...R __._._..._....._ <br /> LEACHING LINE No. of Lines _______/___________ Length of each line_____,1 ----------- Total Length ,I.&V............... <br /> 'D' Box ---/------ Type Filter Material 91 _____Depth Filter Material ............................ <br /> Distance to nearest: Well _________ _ ____ Foundation ______ld__-______ Property Line .___.............I <br /> SEEPAGE PIT Depth ---_-�z -__ Diameter 1�� Number -------/----------------- Rock Filled Yesj�) No i❑/ <br /> Water Table Depth -----------------1749�-----------------------Rock Size --------!�-_`_-_------- '010 <br /> Distance to nearest: Well ----------------------------------------Foundation " ©. Prop. Line ...x_0......... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ____________________________________________ Date ----------------------------------) (_ <br /> Septic Tank (Specify Requirements) --------- ----------- --------------------------------- .--------------------------- <br /> ,r <br /> Disposal Field (Specify Requirements) ---------- .. _. __ � .c___ ----- - ---__ -�- --- <br /> -------------------------------------------------------------------------------23--- ----•---- ---------- ----------------------------------------------------- <br /> ------------------------------------I--------------------------------- <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, 1 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 --------- -- ------ ------------ Title <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -_-_ _ _ <br /> _ ___ _ _______________________- DATE ___ ___ _ <br /> BUILDINQ-PERMIT .ISSUED --------------_. __------ _ - ---DATE .---- -------------- --- <br /> ADDITIONAL COMMENTS --- -------- - ------ --- ------- ------- <br /> - --- ---- ------ - - -- - ----- --------- --------------------------------- -- <br /> --------- <br /> - <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------- -------- <br /> -------------------------------------------------------------- ------------------- ------------------------------ -- - -- <br /> ------------ <br /> - ----- <br /> --------------------- � ------ <br /> Final Inspection by: ---- - ------ Date -- =''- ------- ------ ------ <br /> SAN JOAQUIN �fCAL <br /> HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />