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FOR OFFICE USE: , <br /> . � APPLICATION FOR SANITATION PERMIT <br /> -7--------------------------------------------------- <br /> {Complete in Triplicate} Permit No. ._ <br /> ----------------- <br /> ---------------- <br /> This Permit Expires 1 Year From Date Issued Date Issued <br /> -- --- <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 -.w !---------CENSUS TRACT -------------------------- <br /> Owner's Name ._�1 . -, %-Il57-- - ---------------------Phone ------------------------------------ <br /> Address ------------ -------- <br /> Contractor's Name --------------X------------------------.License # J77f,-;7 — <br /> }------- Phone _ �l-�� ------ <br /> Installation will serve: Residence Apartment House❑ Commercial ❑Trailer Court '❑ <br /> Motel ❑Other -------------------------------------------- <br /> Number <br /> --------------------------------------- --Number of living units:__/.-------- Number of bedrooms ---, ------Garbage Grinder _A/h--- Lot Size ----.-- <br /> Water Supply: Public System and name --- ------ -------------------___-------------------------------------------------------------------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt fl Clay ❑ Peat❑ Sandy Loam M 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 [ ] SEPTIC TANK f ]. Size__-------_------------------------------------ Liquid Depth _----.----_-----_--_._---. <br /> Capacity ------------------- Type -------------------- Material---------------------- No. Compartments ------ ------ <br /> Distance to nearest: Well ____-_____--__-------------------Foundation ------------------_.- Prop. Line --___--_-_-___-_-_-._. <br /> LEACHING LINE [ ] No. of Lines ------------------------ Length of each line-------------------__- ---- Total Length ----_------___-.-.._--.-_.- <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 ---------------- ----------s--------------------Rock Size ------------------------•------- <br /> Distance to nearest: Well -._------------------------------------Foundation -------------------- Prop. Line -_--_-_-__-•----.__-__ <br /> REPAIR/ADDITION[Prev. Sanitation Permit# _--_._--_________________ ' <br /> ------------------- Date ----------------------------------) ' <br /> SepticTank (Specify Requirements) - ------------------------------------------------------------------ --------------------------------------------------------- <br /> Disposal Field (Specify Requirements) --.--/_ ------------------ <br /> ----- <br /> R-®A4----- --V -------- -- <br /> ---------------------------- -----------------------------------------f------------------------------------- -- <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 {�as to become su ect to Workman's Compensation laws of California." <br /> Signed ------- --------- ----------------------------------------------•--- Owner <br /> BY --- --- --"--- ------ ----------------------- Title <br /> ------------------------------------------------------------------------ <br /> --- ------------�,: <br /> other than owner} <br /> ft FOR DEPARTMENT USE ONLY s <br /> APPLICATION ACCEPTED BY ---__W-_.i-- - -------------------------------------------- !-------------. DATE .---7 7t!-------------------------• i <br /> BUILDING PERMIT ISSUED ------- ------------------------ -- -----------------------------------------------------------------DATE ------------------------------------------- <br /> ADDITIONALCOMMENTS ---------------------------------------------------------------------•----- -------------- ---------------------- --------------- --------------------------- <br /> -------------- <br /> -_ -_____._'._ ___ I-+.--------------------------------------------------------------------------------------------------------- --.-___----_.-____.__ <br /> v ____ <br /> Final Inspection by: . ---- ---- ----�-------------------------------------------------------------------------------------Date ------�-- ------- - <br /> - SAN.JOAQUIN LOCAL HEALTH DISTRICT .! <br /> E. H. 9 1-'68 Rev. 5M r <br />