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FOR OFFICE USE: :: _ - <br /> APPLICATION FOR SANITATION PERMIT <br /> Permit No: _7,__`___ � <br /> (Complete in Triplicate) --------- <br /> -4/-A-0------------------------------------ I <br /> ___-;-_______________________ ------------------------ This Permit Expires 1 sear From Date Issued <br /> Date Issued _7.7 s_Y, <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 compliant with County Ordinance No. 549 and existing Rules and Regulations: l <br /> ____CENSUS TRACT ______________JOB ADDRESS/LOCATION . oS�S A-1. i <br /> Owner's .Name ------------- <br /> Address <br /> ----------- L�IIG� ��LPIz—^--: Phone <br /> - -- - ---- <br /> Address ------------------t ®�i5'-� - Cit <br /> - y ------ � - --------------- <br /> Contractor's Name _________-Sell`< -___-__.License # ___________________-_ Phone _____-___.__-_ <br /> installation will serve:--- --- - Residence- �Apartment­House[3 Commercial ❑Trailer-Court <br /> r <br /> ._,.,_--Motel ❑Other -------------------------------------------- <br /> Number of living units:------ __ Number of bedrooms .7-1------Garbage Grinder ------------ Lot Size -__________________________________•:__ <br /> Water Supply: Public System and name----------------------- X------------------------------------------ --------------------------------Private <br /> Character of soil to a depth of 3 feet: Sand❑ Silt lay Peat❑ Sandy Loam ❑ Clay Loam 3 <br /> Hardpan ❑ Adobe'❑ Fill Material ------------ If yes,type- -------------------------- <br /> (Plot <br /> - -----(Plot plan, sh(5wing-siie 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 TANK'[ ] Size__ _____________ __ s_____ ,:..�__-__ Liquid Depth ___ _________ ___ __ <br /> ..._.. T -- _ <br /> Capacity -------------------- Type -------------------. Material--------' ---- No. Compartments-- -------- -- C1 " <br /> Distance to nearest: Well _ :_--------------------------------Foundation - =__ __- Prop. Line ..._ ___ ------ <br /> LEACHING LINT: [ ] No. of Lines ------------------------- <br /> Length of each line_--_-______________-_ Total Length _______-________________ <br /> D' Sox __________ Type Filter Material ___________________Depth Filter Material -------------.____..____............_._--_ <br /> Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line. _________.__•__-_---____ 3 <br /> SEEPAGE PIT [ ] Depth _____ Diameter ________________ Number ---------------------------- Rock Filled Yes ❑ No <br /> Water Table Depth ------------------------------------------------Rock Size ________________________________ 1 <br /> Distance to nearest: Well _____________________-_____--__.- -_-Foundation ______________.__.. Prop. Line ----------- ---------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ____________________________________________ Date __________________________________) <br /> Septic Tank (Specify Requirements) -----------s----- - - - ,.. --•------------- + <br /> - -------------- - - <br /> Disposal Field (Specify Requirements) - - - .-------��----- ----•--------- -------t----------------------------------=------------------•---•----------- <br /> - i <br /> -------------------------------------------------------------------------- ----- --- -- ------- ---- ---- ----------------------------------------- --- ---------------- <br /> ------------------------------------------------------------------------------ '-- \\ i <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 liven- 4 <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 su ' ct to Work�n' ompensation laws of California:" <br /> Signed J�- ---------------�'- - -------------------------------- Owner <br /> BY ------ Title ------------------------------------ ---- -- ---------- ------- <br /> (if other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ------'--�-- ------ -- ----- ---- ------------------------------------------------ <br /> -----. DATE ---- -1�1= ------- <br /> BUILDING PERMIT ISSUED ----------------------------------------------------------------------------------------------------------DATE -------------•----------------------------- <br /> ADDITIONALCOMMENTS --------- ---------------------------------------------------------------------------------------------------------------=-------- _---- <br /> --------- ------ -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> -------------------------- <br /> ------------------------------- .Final Inspection by: � : � _---- --- -------- --- ------ --- -- ----------- __ _ <br /> SAN <br /> i <br /> JOAQUIN LOCAL HEALTH DISTRICT <br /> E.,H. 9 1-'68 Rev. 5M <br />