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i <br /> FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ---- - -------------------------------- Permit No. -- - ---- ------- - <br /> (Complete in Triplicate) <br /> ---------=--------------- ------- <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/LOC TION .//__ <br /> //es- ' ------- <br /> -- <br /> ---------------CENSUS TRACT ------------------------- -, -- - - ---- `�!�-----�'� - <br /> Owner's Name - ------ ---=�<----- -- ------------------------------------- --- --------- --- <br /> --------- one ------------------------------ <br /> _ .Ph <br /> Ile— <br /> Address ----------- �1 `_- - -------------------------------------•--. City <br /> Contractors Name . . _ __.._- <br /> ---------------License # Phone �; / 2`.... <br /> Installation will serve: Residence R<Partment House❑ Commercial []Trailer Court ❑ <br /> Motel ❑Other -------------------------------------------- / <br /> Garbo `�� � <br /> Number of living units:---/-_ Number of bed orru __. _ Garbage Grinder -__-- Lot Size _--____....-.__. _.-- <br /> Water Supply: Public System and name ----- L � � � - -- -• Private ❑ <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.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT f ] SEPTIC TANK Q ] Size------------------_-----r--------------------- Liquid Depth -.-.._-_-----.-------...- <br /> Capacity ------------------- Type ------------------- Material---------------------- No. Compartments ---------_---------- O <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 /> WaterTable Depth ------------------------------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well .__.___-_------------------------------Foundation -------------------- Prop. Line --.-----...--.-------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# --------------------------------- ---------- Date .--.--.---------..-------------.--) <br /> Septic Tank (Specify Requirements) ----------------- ---- - •----------- <br /> - ---- --- - --- <br /> Disposal Field (Specify Requirements) -_ <- -- � - = �' <br /> -------------tt--------------i --------------------------------------------- <br /> -------- --------------------------------------------- <br /> - <br /> -- - .....--------- ------------------------------------------------------------------- <br /> (Draw exi tin nd r uired addition on reverse side) <br /> I hereby certify that 1 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 became uklect t W kman'9EZ <br /> ws of California." <br /> Signed __ -------------------- Owner <br /> BY Title - <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ---C------Z-.-T - - ---------- DATE `' -------- ------------ <br /> BUILDING PERMIT ISSUED ------------------------------ <br /> ---DATE ------------- ----------------------------- <br /> ADDITIONALCOMMENTS ----------- ------------------------------------------------------------------------------------------------------------------------------------ --------- <br /> ------------------------------------------------ ----------------------------------------------------------------------------------------------------------------------•---------------------------------- <br /> -------------------------------------------------------------------- ----------------------------------- ---------------------------------------------------- -------------------------------------------- <br /> ------------X: -I _/ ---- <br /> �''�� Date - ------------ <br /> Final Inspection bY: �--�------ y ----------------------------------------------- - - - - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />