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FOR OFFICE USE: '� <br /> APPLICATION F6R SANITATION PERMIT � <br /> ��- Permit No. <br /> (Complete in Triplicate) <br /> �►' - Date Issued --- /-- <br /> ____________.________- .________-.___________ This Permit Exdtires 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 .- ©_�_ ___��'-,-----_--�1/�T��( OS---------------------------------------------CENSUS TRACT --------_----------------- <br /> Owner's Nameif� �) - . �� --------------- <br /> Phone <br /> Address ---------------------------------------------------------------------------------------------- --. City --- -- <br /> ------------------------------------------ <br /> Contractor's Name ___ ---------------------------------License #/__7.7_6'e�3--- Phone -;`✓ y_s . <br /> Installation will serve: Residence ❑ Apartment House❑ Commercial ❑Trailer Court i❑ <br /> Motel ❑ Other ---- -------------- / X/ <br /> i <br /> Number of living units:--- ---.__ Number of bedrooms .___`"Garbage Grinder -_____ Lot Size _ _: ___________________ <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 ❑ AdobejT 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 [ ] SEPTIC TANKM] Size- - Liquid Depth _ Y_�______________ Q <br /> Capacity ------ Type. ,415 ` Material G`- l/f No. Compartments _-_�F................ 0 <br /> Distance to nearest: Well ------- --------------------------Foundation -----/_!'-_r------- Prop. Line ._, _ _-_-.______ <br /> LEACHING LINE No. of Lines _____�________._____ Length of each line___-V-5------------------- Total Length J__/_................ <br /> 'D' Box A1_0_____ Type Filter Material 1PPC,'_____Depth Filter Material ____/_ ____________________________.- <br /> Distance to nearest: Well ------ --------------- Foundation ---l©__ ----------- Property Line, ___5 .................. <br /> ii <br /> SEEPAGE PIT Depth __,�. _/-____ Diameter _ ____- Number _.___�____________________ Rock Filled Yes Ey No i❑ <br /> Water Table Depth __- ©�j_�_______________________________Rock Size ___ ______--_--___ <br /> Distance to nearest: Well _---"-----------------------_......Foundation ___.l ---------- Prop. Line ___f.............. <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ________________________________ _ Date ______-_________________________--) <br /> SepticTank (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 becWsubje <br /> 's Compensation laws of California." <br /> Signed -- --------- ------------------------------------------- Owner <br /> By --- ------ a------------------------------------------------- Title ----------------------- ------------------------------------------------ <br /> ) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY - L 6f� DATE _ 6 <br /> - ---------------'-7 <br /> /--- <br /> BUILDING PERMIT ISSUED - ------------ ---------------------------- ---------DATE --------------- -------------------- <br /> ADDITIONALCOMMENTS ----------------------- -------- ---------------------------------------------------------------------------------------------- ----------- <br /> -------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ----- <br /> --------------------------------------- -------- - ------ ----------------------------------------------------- -------------------------------------------------------------------------- <br /> --------------------------------- --- - ----- --- <br /> Final Inspection by: ------ ------- ---- -- -------- - - ---- -- -- -- --- - --- Date - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M � C <br />