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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> --------------------------------------------------------- <br /> ---.-•------ 1,� i1 (Complete in Triplicate) Permit No. <br /> --------------------_--------_----_------_--- ---------- t 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/LOCATI S__ 7 - <CC._2-"_ _ __ ------------------------------CENSUS TRACT .......................... <br /> Owner's Name ------ �2�f ..`l: -o-a . ----------- Phone - <br /> Address -- --------- �"-`-- - ----- ---- - f City <br /> Contractor's Name a -' --------License # Phone <br /> Installation will serve: Residence Apartment House❑ Commercial ❑Trailer Court i❑ <br /> Motel ❑Other -------------------------------------------- <br /> Number of living units:--------I___ 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❑ Gay ❑ 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,) G,` <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 [ J Depth ------ ------------- Diameter ________________ Number ---------------------------- Rock Filled Yes ❑ No i❑ <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) --- -4(----- <br /> ----- ---1----- - ----�-�-� -------------------------- ----� ------- ----- ------------.--------------.--------- <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 -------------------------------------------- ------------ �j -- - Owner <br /> --- - - -- -----' �4/ ------ Title ------- ------ <br /> -------- ----------------------------------------- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED ---------------•---------------------------------------------- DATEL -7-�-2-------------------. <br /> BUILDINGPERMIT ISSUED ---------------------------------------------------------- ----------------------------------_DATE ------------------------------------------- <br /> ADDITIONALCOMMENTS ----------------------------------------------------------------•--------------------------------------------------------------------------._.----•---•------- <br /> ----------------------------------------------------------- -------------------------------------------------------------------------------- ---------------------------------------- ------------ --- <br /> --------------------------------------------------- --------------------------------- -------------------------- --------------------- ---- ------------------ ---------------------------------- <br /> --------------------------- �__ <br /> ++ - --------------------------------------------------------------------------------------- <br /> FinalInspection b` l----- -- ---------- ----------------------------------------------------------------------- -Date ---�-j-�-------------------•- - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M -- <br />