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FU OFFICE USE: ' <br /> APPLICATION FOR SANITATION PERMIT �� <br /> -------------------------- Permit No. - ' <br /> (Complete in Triplicate) <br /> This Permit Expires 1 Year From Date Issued <br /> Date Issued _e_` _ 0� <br /> - -------------- _ <br /> ------------------------------ -_ <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 ap lication is m_a�e in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> 3g01 ��r _ <br /> JOB ADDRESS/LOCATION ._ ` ------ ----------=-.-------- ---- ------------- - CENSUS TRACT _ 1 <br /> Owner's Name -------------- liH <br /> < t.sf �------------------------ -------Phone ------------------- --------------- <br /> v <br /> Address ------------ ls% �- 1,2- ------- City _ r._ , <br /> Contractor's Name -----------------------------------------------------------------License # ------------------------ Phone ------------------ ------ <br /> Installation will serve: Residence ❑ Apartment House❑ Commercial :❑Trailer Court [1 I <br /> Motel 2-64her ---- -,.------------------------------ ' <br /> Number of living units:__7-------- Number of bedrooms ----------Garbage Grinder ------------ Lot Size ___________________________________________ k� <br /> Water Supply: Public System and name -------------- ---------------------- -------------------------------------------------------- -------------Private ElJ <br /> Character of soil to a depth of 3 feet: Sand' Silt❑ Clay ❑ Peat❑ Sandy Loam .E] Clay Loam ❑ j <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 seepa pit permitted if public sewer is available within 200 feet,) . <br /> PACKAGE TREATMENT [ SEPTIC TANK'[ Size______v _ ____I _ ------------ Liquid Depth _____ . <br /> Capacity 5-j� - _-,-/- Typey;L_1 --------- Material_r!'rGlg `h__ No. Compartments <br /> istance to nearest: Well ----------------------_Fo dation --------- Prop.'Line <br /> LEACHING LINE i,J No. of Lines --------------- Length of each line___f1 --------------- Total Length .......... <br /> 'D' Box ------ Type Filter Material5�V,�( lr�_ <br /> _ -- Depth Filter Material ------ -•------------------- <br /> Distance to nearest: Well -------- Foundation -------------- Property line <br /> SEEPAGE PIT [ Depth ___________________ Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No <br /> WaterTable Depth -------------------------------------•- --------Rock Size -- ----------------------------- <br /> Distance to nearest: Well ________________________________________Foundation _.----------- ------- Prop. Line ____-....._____---. <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) <br /> C <br /> SepticTank (Specify Requirements) -------- ------------------------------------------------------------------------------------ ----------------•.�------------------------ <br /> Disposal Field (Specify Requirements) -------------------------------•------•------------------------------------------------------------------------------•---------- <br /> existing required <br /> addition h <br /> ---- ---Y certifythat I have prepared th sppl cation and-- --------------- --- - ---- - ----- ----- <br /> tha <br /> hereb <br /> on reversee <br /> side) <br /> e 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 ------- ---------------------------------------------------------------------------. Owner <br /> BY ---------------------------- ------------------------- - ------------- Title ------------------------------ ------------ ---------------------------- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY --------- _e_ _, <br /> --------------------------------------------------- DATE ---� '�` ;- 1 --------- <br /> BUILDINGPERMIT ISSUED --------------------------------------------------------------------------------------------------------_DATE ------------------------------- ----------- <br /> ADDITIONALCOMMENTS ------------------------------------- ------------------------------------------------------------------------------ -------------=---------------•------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ---------------------------------------------------------------------------- ------ ----------------------- <br /> ---------------------------------------------------- <br /> ---------------------------------------------------------- - <br /> - - --------- <br /> Final Inspection by: _____________ ____ Date _� 21� --- <br /> -- ------------------------------------------------------------------------- <br /> - - -- - -- - ----------------------- <br /> SAN <br /> - -------- - -SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />