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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> ------------------------------------- <br /> -------------------- (Complete in Triplicate) Permit No: <br /> 4­2 <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 Ordin nce No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION __110_'__ ------ /7 V ------------------------------------------------CENSUS-TRACT .-___ <br /> Owner's Name -- 7-1 .41 - -------V _U-1 _ ./ f�------------------------------------------------ Phone <br /> Address --- �_ _,2 - _7__s ---tv-----/�-------------- City!//1 —? <br /> ------------------------------ <br /> Contractor's Namer/__`�`-____.______-___________________.License ----- Phone _ r !r <br /> Installation will serve: Residence ❑Apartment House❑ C mercial ❑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 J9 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 /> -- L <br /> PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] Siz - t--3_)< _Xe_0-__-___-___ Liquid Depth _19 _________________ <br /> Capacity e ¢Z"----,-- Type Material_ No. Compartments � ------- 00 <br /> "a Distance to nearest: Well _______4 __1______-___-____Foundation __ _© -------- Prop. Line --- - ------------ 6 <br /> LEACHING LINENo. of Lines _______ <br /> [ ] I_____________ Length of each line-- --------- • Total Length _,c��................ <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 to nearest: Well _______________________________________Foundation -------------------- Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ____________________________________________ Date ----------------------------------) 7 <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, 1 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 otkthanown r) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY . -__________-____-------------------------------------------------------- <br /> __ _ <br /> _-____. DATE _ 'JS'.75-__._-_-__-._-___ <br /> - <br /> BUILDINGPERMIT ISSUED ----------------------------------------------------------------------------------------------------------DATE ----------------------------------------- <br /> ADDITIONALCOMMENTS ------- ------------------------------------------------------------------------------------ ---------------------------------------------------------------- <br /> --------------------------------- - ------ ---------------------- --------------------------------------------------------------------------------------- <br /> ______________________ ____________ ____ _ ________._ ________ " ___ /c --------- <br /> ____ ___ __ _ 'C/ <br /> Final Inspection •---- Date = ! - - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />