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sFOR OFFICE USE: APPLICATION--FOR SANITATION PERMIT //� <br /> ------- ------------------------------------------------ <br /> Permit No. <br /> (Complete in Triplicate) <br /> • , ; <br /> �} ..� Date Issued ./ <br /> Q This Permit Expires 1 Year From`Date Issued •: <br /> -------------------------- <br /> i <br /> Application is hereby made to the San Joaquin Local Health District for a.. per to construct and install the work herein <br /> described. This application is made in compliance with County Ordiriance No.T 549-�and existing Rules and Regulations: <br /> . <br /> JOB ADDRESS/LOCA IW ------ --- ----------------�---`---- ::r-- -------------CENSUS TRACT -------------------------- <br /> �^ f/, <br /> Owner's Name -_t ( . --------------------Phone._ �_?.✓ .. <br /> ---- ---------------------------- ------- -----------_- <br /> Contractor's <br /> ----------------------- <br /> --- ----------�-�� --�'------/------ ------------ ---------------------------. City '----------- <br /> So-xsJ License #���"��------- Phone �6�-_��Q--7------ <br /> Contractor's Name ------ --- ------- - - ---- �---------------- -------------------- � - <br /> Installa#ion will serve: Residence ❑ Apartment House'❑ Commercial ❑Trailer Court ;❑ <br /> Motel ❑ Other --_6- <br /> Number of living units:------------ Number of bedrooms ------------Garbage Grinder .___--______ Lot Siz <br /> e� 7xb73z <br /> Water Supply: Public System and name -------------------------------------------------------------------- <br /> ----------------- - ---------------- <br /> ----- '------------------------ ------------------------------ ----------Private [It - <br /> t Character of soil to a depth of 3 feet: Sand'❑ Silt El at Peat❑ Sandy Loam El Clay Loam [I <br /> Hardpan ❑ Adobe`[ FiII,Mate`ria! _---�.__ if yes,type ---------------------------- <br /> (Plot plan, showing size of lot, location of system-in relation #o wells, buildings, etc. must be;placed on rrever`se�side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) ' <br /> a <br /> PACKAGE TREATMENT [ } SEPTIC TANK N Size--------- ""X" ------------ Liquid Depth ___ -------------- <br /> Capacity/ vl_ Type ----- Material_ "-_"- No. Compartments ------ --------------- U' <br /> 6. Prop.If Line - 5----- -------- Q <br /> �. Distance to nearest: Well ______'�______________________ _Foundation _l� <br /> { r ; e <br /> LEACHING LINE No. of Lines _ _ � ______ Length of each line_----X------"-_ "�---- Total Length ___ .__4__________________ <br /> 1 .. <br /> 'D' Box __-- Type Filter Materia! ::---Depth Filter _Material __-lcY______ ________________________• �i .• <br /> Distance to nearest: Well '"_ ___-'____= =-;_.Foundat-ion. ___��r ti:------ Property Line ____-4F _ .----- <br /> SEEPAGE PIT Depth _.. ------- Diameter _3;� ...... Number, ----------------- <br /> ----- Rock Filled Yes V No <br /> WaterTable Depth ----------------------------------------- ------- <br /> O <br /> ' Distance to nearest: Well --------------------------------------.-Foundation ____ Prop. Line ---------------------- D <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------"Date ---------------------------------- <br /> Septic <br /> _________--____ ---Septic Tank (Specify Requirements) -------------------------------------------------------:`----- ----s--------- I---------------------------------•--------------4------------ <br /> Disposal Field (Specify Requirements) ____________ __• - <br /> _ __ _.. <br /> i -_ r x 4 <br /> - ------------ <br /> -----------=--------------------------------------- <br /> --------r _--------------------------------------------- <br /> (Draw existing and required addifion 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's Compensation laws of California." <br /> .,.-Signed ------- -------- --- ------- <br /> t ---------------- ,Owner <br /> -- ------------------------ ------- <br /> t <br /> BY - <br /> ------------------' -.---' ;Title <br /> (if er than owner) <br /> FOR ,DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY C'� T---------'---------------=----------------------------------- DATE _ 1--------------- <br /> _ -------DATE --------------------------------------- <br /> BLIILDING PERMIT ISSUED -------- ---------------------------------------------------------- ---------------- ----------------- <br /> ADDITIONALCOMMENTS ------------------------------------------------- ---------------------------------------- ------------------------------------------------------------------- <br /> --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ---------------------------------------------------------------------------- ------------------------ -- --------------------------------------------------------------------------------- <br /> r -------------------------------------- - -- <br /> - - - --------- - <br /> Final Inspection by: ____`__ <br /> Date ---- > _ <br /> --- - -- ------ - <br /> SAN JO QUIN LOCAL HEALTH DISTRICT ,_- <br /> F <br /> E. H. 9 1-'68 Rev. 5M <br />