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..FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT l <br /> Permit No: <br /> (Complete in Triplicate) <br /> Date issued __�---� __17_1 <br /> This Permit Expires 1 Year From Date Issued <br /> ---------------------------- <br /> r 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 Co ty Ordinance No. 549 and existing Rules and Regulations: <br /> - <br /> - <br /> Z___ <br /> czc f --�-�v-_e__-CENSUS TRACT -------------------------- <br /> I JOB ADDRESS/LOCATION ----- ____ - _ --- -- // <br /> Owner's Name ''�^ `------------- <br /> / : ��- -{ ----- --------_-------- J Ph ne <br /> { r' f - -0-�� City --- `✓---I---------------'------ -- ----- - -- -- r <br /> Address - - ---- ----- -- -- ------ <br /> f <br /> Contractor's Name f _ ------------°------ .License # 1. ----------- <br /> Contractor's Name ----------------------- License <br /> ------------- ------ <br /> 1'�r court <br /> Installation will serve: Residence ❑Apartment House Commerce I: ler Court 0 <br /> Motel ❑ Other -.-z---------------------•-------•---------- <br /> Number of living units------------- Number of edrooms ----------- Grinder------------- Lot Size le-0 --------------------- <br /> f~,` _ - Private <br /> Water Supply: Public System and name __- - __--_L4!� � ❑ <br /> Character of-soiI to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam -❑ Clay Loam:❑ <br /> Hardpan❑ Adobe'❑ Fill Material ------------ If yes,type ------_-------------------- <br /> y . t <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'[[ ze-_ ---Y S�' _ Liquid Depth _E lz _____________ <br /> s i 4 -- - I�t - -_ No. Cornpartments ----s' J------_-••- <br /> Capacity 1;W0---,--- Type _ _l� -Materia -- <br /> Distance to nearest: Well - .-__-_--__=__ _ ------___'''Foundation ____ _______ Prop. Line �__________________ <br /> It <br /> LEACHING LINE No. of Lines ------J--------- Length of eacFi•,line----_T - Total Length ,__ ©_________________ <br /> 'D' Box &C---.- Type Filter Material ------Depth Filter Material -_ - --------------------------------- <br /> Distance to nearest: Well ------ _--f--'Foundation ----/_Age--------- Property Line ----------- <br /> SEEPAGE PIT [&K Depth , _______ Diameter ' _ i-_= Number"`-__._ __-__ <br /> y- _"----------- Rock Filled Yes 0tel"i❑ <br /> Jif <br /> Water Table Depth ------------�--C�---�------=-------=--------Rock"Size --,��-x-s-----•-------- r <br /> Distance to nearest: Well ---------------_'p`F _____....--____--Foundation _____/ -__ Prop. Line _f.__-_-_.__--- <br /> REPAIRfADD1TION(Prev. Sanitation Permit# -----------------------t ' <br /> ----=----- - Date ---=------------------------------} <br /> f <br /> SepticTank (Specify Requirements) ---------------------------------=-=------------------------------------:.-------- ------�'------- -----------•----------------------------- <br /> 4 f. <br /> k Disposal Field (Specify Requirements) ---------------------------------------------------------------------= ----------------- -------------------------------------------- <br /> t � ' <br /> i ---------------------------------------------- ------------------ <br /> ----------------------------------------------------------------r--------------------`--------------'------------------------ <br /> f ------------------------ ----------------------- ------------- ------- -------------------------------------------------------------------------------------------------- <br /> [ (Draw existing and required addition on reverse side) <br /> fj 1 hereby certify that t 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: 4 <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 Compensattbn laws of California." <br /> Signed ---------------------------------------- ------------------ - Owneri <br /> -- --------------------- <br /> B �-- `-------------- ---- -------------------------------------- <br /> ------- ---- --------- Title <br /> (If other than ne <br /> OR 'DE RTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ------ -----------------.,--- DATE -- <br /> - <br /> BUILDING PERMIT ISSUED - ,t'---------------------- DATE ------------------------------------------- <br /> ADDITIONAL <br /> --------------------------- --- <br /> ADDITIONAL COMMENT --- --- - ------ ----- ---- ------•---------------------------------------I---------------------------------------------------- <br /> ------------- -------------------------------------------------------------------------------------------------------------------- <br /> ' ----- --- --------------------- ---- -------------------------------------------------------------------------------------------------- ----------------- <br /> 4 ---- - <br /> ------------------ -------- ---- ------- - - -------------------------------------------------------------------- ----------------- ----------------------------------- <br /> Final Inspection by: ----- --- ----'`--- ----------------------------------------------------------Date ------- -----:------- <br /> ANAQUIN LOCAL HEALTH DISTRICT _ 51 <br /> E. H. 9 1-'b8 Rev r <br />