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OR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ---- --------- ��= = � = ll--------.o . Permit No. -7-1 <br /> I y I. <br /> (Complete in Triplicate) <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 X <br /> __ ____,...� _'____ - ------------------CENSUS TRACT --------------._ <br /> Owner's Name -------- .... K� ,�.,, _ Phone .X -ye <br /> Address LFd K r City <br /> Contractor's Name _______._________ __ __________________ _ ___ _ Cif____..___._____.License # 60-P- 1_____ Phone <br /> Installation will serve: , Residence Apartment House❑ Commercial ❑Trailer Court ;❑ <br /> Motel ❑Other ------------------------ --------- --------- <br /> Number of living units:----f------ Number of bedrooms _-___,?j____-Garbage Grinder ------------ Lot Size __._-----Z�__ -T-__.._.. <br /> Water Supply: Public System and name ---------------------------------•----------------------------------------------------------------------------.PrivateA <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.) W <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 ------ ................... <br /> Capacity ---- ------ -------- Type -------•------------ Material------- --- No. Compartments ..................... <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 ________________________ Foundation ____ ------------------- Property Line ........................ <br /> SEEPAGE PIT [ ] Depth ------- Diameter ________________ Number -------------------------------- Rock Filled Yes ❑ No i❑ <br /> Water Table Depth Rock Size -------------------------------- <br /> Distance <br /> ______________________________Distance to nearest: Well --_____________________________________Foundation --------------- ---- Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ____________________________________________ Date ________-.•-----_---__________--•-) <br /> Septic Tank (Specify Requirements) ----- <br /> -----------------------------------------------------------------------­--------- <br /> --------- <br /> Disposal Field (Specify Requirements) --------- w <br /> ------`�T--- ------------------------------•--------------- <br /> -i--- --- <br /> `' ---- ------ -- - <br /> -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> (Draw existing and required addition on reverse side) <br /> 1 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 ----------------------- <br /> - (f - ---------- Owner <br /> .BY ------------- - 2 ------------------------------ Title ---------- <br /> the <br /> n owner) <br /> ENT USE ONLY <br /> APPLICATION ACCEPTED BY -------� - ------ --- --- -- --- - ------ DATE"�` --------- <br /> BUILDING PERMIT ISSUED __-_______ __ __. - ._ -_DATE ___________________________________________` <br /> ------- - - -------- ------------------------------------------------- <br /> ADDITIONALCOMMENTS --- --- ---- - ------- - ------- ------ •------------------------------------------------------------------------ ------ ----------------- <br /> --------------------------------------- <br /> - - _ <br /> ------------------------------------ -- --------- -- -----------;19-/------- <br /> ----------/1'f-f ---- ------ ----------------/X-;-- - ----; x <br /> ----------------------------------------- ------- --- --- --- ----------- ----- <br /> - -- - -------- ----------------------- --te - <br /> FinalInspection by: --------- ---� --- -- -- ------- --- --- ------ - - -- --- --------------------------------------.Date ----- -- ---------�---�-------.-- <br /> SAN JOA IN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />