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FOR OFFICE USE: APPLICAVON' FOR SANITATION PERMIT <br /> ------- ------------------------------------------------- Permit No. ---7- -_ <br /> (Complete in Triplicate) <br /> �"� -This\Permit-'Expires t Year From Date Issued Date IssuedD6-" <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 /> c- -------- ----------- -------- ------------------- <br /> - ---CENSUS TRACT ------- <br /> JOB ADDRESS/LOCATION _-; -5-------- -------- <br /> ___ __ _ <br /> Owner's Name ------ -------- --- ----------- PhoneTb � <br /> -- - <br /> Address a_ `f ---- 1 :_: City <br /> Contractor's Name --- ------- ---- LCI(---- --- ---------_--------License # - ��----- Phone -�_ l� Q ---• <br /> Installation will serve: ResidenceApartment House❑-Commercial !❑Trailer Court 1E]+ Mote ❑ Other -------------------------------- <br /> Number of living units:-------- Number of bedrooms ___Garbage Grinder ---_------'-- Lot Size ____�______/__ ________________ <br /> Water Supply: Public System and name ___________________ ..1. } ❑ <br /> I <br /> Prwate <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ 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 I Size------------------------------------------------ Liquid Depth ------------.----..------- <br /> Capacity -------------------- Type --------------------'Material------ ----------- No. Compartments ----------_---- <br /> Distance to nearest. Well _________________s__--___________--Foundation'y _ _:_______________ Prop. Line --------------I....... <br /> f <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: Wel'I ::______._________,__ Foundation`_______ ________________ Property Line <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ________________ Number ,_--------------f------ ----- Rock Filled Yes ❑ No i❑ <br /> Water Table Depth ------------------------- - hk:1 <br /> . A <br /> - ^.Rock Size -------------------------------- f <br /> Distance to nearest: Well ------------- --------------------------Foundation -------------------- Prop. Line _______________.____. <br /> � k <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------- --------------------------------`__ Date ----------------------) <br /> Septic Tank (Specify Requirements) - <br /> - ;- ---------------------------:------------ ------- <br /> -------------------- <br /> -------•---------•- <br /> Disposal Field (Specify Requirements) ______ ----------- "•-t ` {tel <br /> o ///rr:- <br /> ------------------------------ --------- :--------- -- ------ <br /> ---------------------------------- -------= - = - - - - <br /> i -(Draw existing nd required addition do 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 Lacal 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 G "tJ - Owner ti <br /> B ------ ` Title -`--'=-=-- -- --�- --- - - -------------- <br /> (If <br /> - - - -(If other than owe <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY - . DATEj O _7 _ �' <br /> BUILDING PERMIT ISSUED ----- --------------------- ----------------------- ------- ---DATE --------- -------------------------------- <br /> ADDITIONALCOMMENTS ---------------------------------------------------------------•--•----------------------------------- ---------------------------- --------------------------- <br /> ------------------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> _ - <br /> ----------------------------------------- <br /> ­­ <br /> --------------------------------- <br /> - ------- �--- ----------------------- - - - ------ - ------- -----------------------------------------+o -3r7a--------------- <br /> FinalInspectionbY= � _ - -- --•-------------------•-------•---•---•--------• -• -- -----------------------------Date -- --1---- -------- --- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M (�� <br />