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i <br /> FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> —01 Permit No. <br /> --------------------- ------------------------------- <br /> (Complete in Triplicate) <br /> This Permit Expires 1 Year from Date Issued Date Issued <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 Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESSAOCATION .---- - ..-_- fes . - 1`7----------------------------CENSUS TRACT ------------------------ <br /> Owner's Name_ ,. ---------------------------------Phone <br /> ------------------- ---------------------- <br /> Address <br /> '5727------------------------ City <br /> Contractor's Name -- '01 _ _IV4---------r,----- --------------------License #c;?�?14_J�g Phone = <br /> Installation will serve: . ` ~ Residence [Y'Apartment House-[] Commercial"❑Trailer Court i❑ <br /> ­- <br /> Motel ❑ Other ----------------------------------------- - <br /> Number of,living units:--- _---- Number of bedrooms __ __------Garbage,Grinder"_/VP_ Lot Size 4__ael_llel--- <br /> Water Supply:,Public System and name ---�JF1,V _-- _ ---------------------------------------------_-Private F-1r i� t •ri <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay E] Peat❑' Sandy Loam ❑ Clay Loam`[] <br /> Hardpan ❑ t Adobe Xt-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.) Ilk <br /> j NEW INSTALLATION: (No septic tank or seepage pit, permitted if public s ,) <br /> ewer is available within 200 feet <br /> PACKAGE TREATMENT [ ] SEPTIC TANK Size__ _ --------------------- Liquid Depth ________________. <br /> Capacity/.f Typ � °� -- Material - l __ No. Compartments __7r- ........:.... <br /> * • ____ <br /> �-; Distance to nearest: Wel -7____777_� ---------------Four+dation -Q-----:-7777-- Prop. Line <br /> LEACHING LINE ° No. of Lines ofe ach line___� _____________ Total Length -- ------------------ <br /> ;D' Box Type Filter Material/-�A Depth Filter Material� _�7:777_______________________ <br /> --- -_ ------- Prop __ _--Property Line ..__ <br /> Distan to nearest: Well ______ ___ Foundation ' <br /> SEEPAGE PIT Depth __� ________ Diameter � _______ Number ------ ------------------- Rock Filled Yes No .C3 <br /> Water Table Depth -----1-6, ------------------------------Rock Size/---All----- <br /> i Distance to nearest: Well ---_---__'- ' .................Foundation ?__________ Prop. Line _V___-.______._.-_. <br /> REPAIRJADDITION(Prev..Sanitation Permit# -------------------------------------------- Date ___-______________________________) <br /> Septic Tank (Specify Requirements) ------ --------------------------------------------- --------------------------------:---------- ------,---------------------------- <br /> ` a. <br /> Disposal Field (Specify Requirements)- -------------------------------------------------------------------------------------------------------------- ---------------------- <br /> F .Y <br /> ---- ----------------------------------------------- --------------------------------------------------------------------------------------------------------- - <br /> ___________________________________________________________________$____________.______________________-______,_______________________________-____-____________.____._______.________________________--_-__ <br /> T _ (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 <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed -------------------- --- ---------- Owner <br /> a <br />+ BY ----= ------ ��--- -------------------------------- Title _-��� <br /> # ------------------------- <br /> (If er than owner) <br /> s � <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE ��" - �j <br /> ------------ <br /> BUILDING PERMIT ISSUED ----------------------------=------------------------ -------DATE -------------I----------------------------- <br /> -------------------------------------- <br /> ADDITIONAL COMMENTS ------ ------------- ---- --------------------------- ------------------•---------------- <br /> - - -------=------------------------- -- ------------- <br /> - <br /> -------7777___ 7777_ <br /> ------------- _ 7777-_-_ <br /> _ _ _ _ _ _ 7777__ 7777_ <br /> Final Inspection by: = � ---------------------------------------.Date ------------------------------ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />