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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ------------------------- ---------- ------ ;� -�f6 Permit No. <br /> (Complete in Triplicate) <br /> ---- ;f This Permit Expires i Year From Date Issued bate 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/LOCATION <br /> ------CENSUS TRACT -------------- ----------- <br /> _- .-- �. ---- -- --- ----- y <br /> Owner's Name----- ------ <br /> Phone%'--«- g-,-1L-cit <br /> Address <br /> -- ---------------------- City = - - --- - <br /> Contractor's Name , _ -- _- ------- _ - - ----------------------License # = L .- PhoneYri <br /> Installation will serve: ResidenceXApartment House❑ Commercial:❑Trailer Court i❑ <br /> ` Motel ❑Other ------------------------------- <br /> Number of living units:- --- Number of bedroo/rns p_ -'Garbage Grinder ------------ Lot Size -- 7 ---------- <br /> Water Supply: Public System and name --------------- .... ------------------------------------------------------Private ❑ <br /> Character of soil to a depth of 3 feet: k Sand'E] 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 260 feet,) <br /> PACKAGE TREATMENT [ I SEPTIC TANK:[ ] { Size------------------------------------------------ Liquid Depth -------__..--------,----- <br /> Capacity -----------------•-- Type -------------------- Material----------------- ---- No. Compartments ---------•------ tl� <br /> Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line .--_-__-_:--_-_--_--- <br /> LEACHING LINE [ ] No. of Lines ------------------------ Length of each line- - ,-- ._.------ Total Length _-_----_--._- ...... <br /> 'iY Box ------------ Type Filter Material -__-_____-_-----_Depth Filter Material -------------- <br /> Distance to nearest: Well ---i-------------------- Foundation ------------------------ Property Lime_ -_.--.-_-_-._---._._-_ <br /> w SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number ----------------------------- Rock Filled„ Yes ❑ No <br /> Water Table'IDepth ------------------------------•-----------------Rock Size -----------•-------------------- <br />'F Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ---------_--____-.__•- <br /> r y <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date --•-------------------------------) <br /> Septic Tank (specify Requirements) --- <br /> -------------- <br /> ------------------- <br /> --- -- - <br /> i� ' <br /> Disposal Field (Spec'fy Requirements) -- - - --------- -- ----- = <br /> 4 5 <br /> r <br /> --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> f (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 Saar 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 --------------- ------------------- , µ <br /> (If other than owner) <br /> f. r <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ___------- ------ DATE ---- _- -� ."--?.v------.--------- <br /> BUILDING PERMIT ISSUED ---------- ----------------------------------------------------------- --------------DATE °-----•------ <br /> ADDITIONAL COMMENTS ------- t <br /> -------------------------------- -------------------------------------------------------------------------------------------------------------------------------- --------_ -------------------------- <br /> ---------------------------------------------- -------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ---------- = <br /> -------- - <br /> Final Inspection b --- <br /> p Y= --�--- - --- --------- ------- ----------- --------------------.----------------------`-=--------`==---.Dated J-T.-�.6 - - ----- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />