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EOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> --- ----------- -- -----------------F �� _ Permit No. <br /> (Complete in Triplicate) �, .t... <br /> ---------- --- <br /> -Y _- This Permit Expires i Year From Date Issued Date Issued ._-________ z <br /> - ---------- <br /> Application is hereby made to he 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 /> I <br /> JOB ADDRESS/LOCATION ..-, �/� .- �. - CENSUS TRACT �r------------ ----_ <br /> Owner's Name .--rjC.�\ff ..........F ` Z `a --------------------`--------------- ----------------- -- -------------. <br /> _Phone &vl- <br /> ? <br /> . ....--_ ------------------- CitY S C�ral----------- 'Address ---------------- <br /> Contractor's Name ------------------------------------ -----=---------.License # o41411907 ---- phone <br /> Installation will serve: Residence K Apartment House�O'Commercial ❑Traiter Court ,❑ ] <br /> Motel ❑ Other __-_._ <br /> F ! <br /> of � <br /> Number of-living units:-.- ------- Number of bedrooms _.Garbage Grinder . 4_ Lot SizIe __ . a-- �, _____t....._.. <br /> Water Supply: Public System and name -------------- - --------- -------------------------- ------------- ---------------'_'--Private ❑ ; <br /> Character of soil to a depth of 3 feet: Sand❑ Silt Cay ❑ Peat❑ Sandy Loam F1 Clay Loam ❑ <br /> `Hardpan ❑ Adobe ' Fill Material ----- ------ <br /> 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 [ SEPTIC TANK'[ ] Size------------------------------------------------ Liquid Depth --------------._-`.--__--- <br /> �, Capacity --- Type -------------------- Material-------- ------------- No. Compartments -- --- --------------- <br /> Distance to nearest: Well ------------------------------------Foundation --- ------ Prop. Line .--.---------:-------- <br /> I' n f <br /> LEACHING LINE No. of Lines ..._-_ Length of each line_,�lJ`r-��� Tata) Length ___._ -__Q " <br /> ------- -- -- <br /> / <br /> 'D' Box ---/------ 7ype�Filter Material _____ _________Depth Filter Material --------- - f ______________________ <br /> i Distance to nearest:-Well -------- Foundation ----- --------- Property Line ---- <br /> -SEEPAGE PIT [ ] Depth ____________________ Diameter ---_-__---_----_ Number -.---__------.-__________-- Rock Filled Yes '❑ No 0 ) <br /> _ <br /> t Water Table Depfh -------------------------------------------------------Rock Size ------------------------------ <br /> Distance to nearest:,Well—:--_----------------------_-------------Foundation -------------------- Prop. Line -_--_____-___-__--__ <br /> REPAIR/ADDITION{Prev. Sanitation Permit#1------------------------------------------- Date -----__-____-_._-__.-----_-_-_---_) <br /> SepticTank (Specify Requirements) ------------------------------------=-------------------------------------------I--------------------------I-------------- •----•-------- <br /> Disposal Field (Specif,`y- Requirements) ------------------9Q..t:---. -.�r�xc� --------------------------------.-------------- <br /> . <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 Joacluin'Local Health District. Home owner or licen- <br /> sed agents signature certifies the following:= t s <br /> "I cekify 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 became subiect to Workman's Compensation laws of California." <br /> f ------------------------------- ---- ------------- { <br /> Signed --- ----------------- f Owner <br /> B Title <br /> Y <br /> ---- ------------------------ <br /> (If other than owner) <br /> ' DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -- - ----------------------------------------------------------=----- DATE -_ ----- -- <br /> BUILDING PERMIT ISSUED ----- --- - --------- -------DATE --------------------------- <br /> ADDITIONAL COMMENTS ______ ___ _____ ___ _ ' <br /> ------------------- ---------------------------------- - --- ----;------------------------------------------- <br /> R <br /> - =---------------------------------- - ---- - --- --------- ------------------- --------------- ------------------------ ------------------ == <br /> Final Inspection b ---------------------Date ---- -?'-,--_-.i__------ <br /> SAJOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev..5M - - <br />