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FOR OFFICE USE: <br /> r APPLICATION FOR SANITATION PERMIT <br /> ------------------------"' - Permit No. . � <br /> ----- .9p <br /> --------------- <br /> (Complete in Triplicate) <br /> Date Issued _7_ <br /> 4RD --------------- This Permit Expires 1 Year From Date Issued 1 <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/LOCATION - ��ow� /------1 '��`� s� s°``P----------------------- ------CENSUS TRACT - <br /> Owner's Name - Phone <br /> Address ------ S�W/��"`'----------------- :--=--------------------------------------- y - <br /> Contractor's Name ----- __k_467Z6 -__.License # ra- � _ Phone <br /> Installation will serve: Residence)eApartment House,❑ Commercial ❑Trailer Court i❑ <br /> Motel ❑Other ------------------------------------------ s 1 <br /> Number of living units:_____'__ Number of bedrooms ____Garbage GrinderLot Size ------------------ <br /> Water <br /> -__.-___--_--__Water Supply: Public System and name �� ��d' .`_ --------------------------------------------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 [ I SEPTIC TANK I ] Size------------------------------------------------ Liquid Depth --------------------_._.__ <br /> Capacity -------------------- Type -------------------- Material------- ---- No. Compartments ----- ----- <br /> Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ---------------------- <br /> LEACHING <br /> __---- _:_.______LEACHING LINE [ ] No. of Lines ------------------------ Length of each line---------------------------- Total Length -----------_-____:_--_--____ <br /> 'D' Box *--------- Type Filter Material _f-------------------Depth Filter Material -------------------- ------------------ <br /> Distance to nearest': Well _________________ ___ Foundation ------------------------ Property Line _____-___________--__ <br /> •SEEPAGE PIT [ ] Depth ___________________ Diameter ---------------- Number ____.__- __--_____________ Rock Filled Yes ❑ No C] <br /> a <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) ---- ------- - --------I---------------------------------- <br /> ----------------------- <br /> Field (Specify Requirements) _-_- ____.. ------ ,y <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'yCom nsation laws of California."Signed ------------------- ---- ----------=-------- -- Owner <br /> By --------------------------- Title ------- ---------- <br /> (If er than o-- er <br /> R DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY _ +, -: - - -------------------------------- -------------------- DATE ` <br /> BUILDING PERMIT ISSUED ---------------------- Y -- -- --- - ---- -----------------_-DATE ------------------------------------- <br /> ADDITIONAL COMMENTS ---------- -----__��--------- �---�- '----------_.>,.�; � --------------------------------------------------=--------------------------- <br /> --------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------- ------ <br /> ----------------------------------------- -- ------------- ------------------------------------------------------------------------------------- <br /> ---------------- - = ------------------------------------ ------- <br /> Final Inspection b : Date ........_--------------------` <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />