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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> !' `--------------- <br />------ _---�_3J - Permit No: �_ <br /> ------------------- <br /> (Complete in Triplicate) -------_-------- <br /> Date Issued <br /> ---------- - <br /> This Permit Expires 1 Year From Date Issued 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 ------- --------------------------------------------------- ------------------CENSUS TRACT ----------- <br /> - �--MY-----! t ��_rt_4d1_ r.5------ -------------:----------------- ----- -----------Phone d A'3 ---------//_�-- <br /> Owner's Name-7 _ _ _ �J ` __ __b_ f�/._ 1 <br /> Address ----- / � �� �, ? �-----l7 L�-�?/` IL __CG --------------- City <br /> .16 <br /> Contractor's <br /> Contractor's Name ___ f-------------- <br /> ______-___-__---____-__-__--------License `fir /-- ------ Phon �4? <br /> Installation will serve: Residence E]Apartment House❑ Commercial ❑Trailer Court !❑ <br /> Motel ❑Other ------------------------------------------ <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 ❑ IN. <br /> Hardpan ❑ Adobe ❑ Fill Material ------------ If yes,type ---------------------------- V <br /> W <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) v <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 ------ terial---------------I ----- No. Compartments ...................... <br /> Distance to nearest: Well ______________________ _____________Founda on ---------------------- Prop. Line -...______________..._ <br /> LEACHING LINE [ ] No. of Lines _------------------------ Length of each line________ ___________________ Total Length ,____.---_.-_---_-.___._.._ <br /> 'D' Box ____________ Type Filter Material ___________________De th Filter Material __-_____-__________--________-------..._-.._ <br /> Distance to nearest: Well ______________ _________ Foundati n ------------------------ Property Line ........................ <br /> SEEPAGE PIT [ J Depth -------- ----------- Diameter _ ___.-_-_-_-__ Num r _______________.________ Rock Filled Yes C] No C <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 /> Field (Specify Requirements) __ ' _. �__f=- __ -: __ I _l /!___ 1 _____ <br /> j�------------------------------------------------------------------------------------------------------------------------------------------------------------------------ <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 become subject to Workman's Compensation laws of California." <br /> Signed --- --------- Owner <br /> BY ------- - ---- --- - ------------------�-/' --- ---------------------------- Title ----------------------------------------------------------------------- <br /> (If of er than owner) , <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY _____________ ___ 4_:__ •-_.__-_____. <br /> DATE l <br /> BUILDING PERMIT ISSUED -- -------------------------------------------------------------------------------------_DATE ------------- ----------------------------- <br /> ADDITIONALCOMMENTS -------------------------------------------------------------------------------------- ------------------------- ----------_-- --------_---------------- <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------•-•------------------------------- <br /> ------------------------------ ----------'-------------------------------------------------------------------------------------------------------------------------------------------------- ------------ <br /> ' -- - - - - _ ------=------- <br /> -- - ---- <br /> FinalInspection by: ---------------- -------- ---------------------------------•------------------ -------------------Date <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />