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- / FOR OFFICE USE: <br /> VVV APPLICATION FOR SANITATION PERMIT <br /> - •------------------------ Permit No. _�=.1�_ _3 <br /> (Complete in Triplicate) <br /> ---------=----------------------------"---------- ----- <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 permit to construct and install the work herein <br /> described. This ap lication is made in compl' ce with County Or once No. 54 and existing Rules and Regulations: <br /> Aff <br /> JOB ADDRESS/L CATI N'/ .__. �N -. _ <br /> _-..'44 /4-70_.CENSUS TRACT <br /> Owner's Name ---- -------v7r. c -------Phone -1-----j"'---------g------------ <br /> Address -------- --------- i <br /> ----------------------- City <br /> ------------- ----------------------------- <br /> Contractor's Name ----=--------License # lf� Phone -�6�-� Q7- <br /> Installation will serve: Residence ❑ Apartment House-0 Commercial :❑Trailer Court ;❑ <br /> Motel ❑ Other ----------------------------------- <br /> Number of living units:--____-____. Number of bedrooms ________-_-Garbage Grinder ------------ Lot Size ________________-_______________________ <br /> Water Supply: Public System and name -----------------------------------•------------------------------------------------------------------- --------Private <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam CK Clay Loam X <br /> Hardpan ❑ Adobe ❑ Fill Material ------------ If yes, type ___________________________ <br /> (Plat 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' Size____.____ --_-__________________ Liquid Depth _. ----------- <br /> Capacity <br /> -______._.__. <br /> Capacity( _r*wl Type -,�`_-�-,_`�_'_(r�_'____ Material._'_ No. Compartments <br /> Distance to nearest: Wel! -------S-01 <br /> __*________________Foun`dation -----fQ___7�-- Prop. Line ____�___._.___..__ <br /> LEACHING LINE No. of Lines -------- ---------- Length of each line-------100- r_________ Total length ------------ <br /> 'D' Box ---C"'.- Type Filter Material __ ___Depth Filter Material ----lR---------------------------------- <br /> Distance <br /> ----_____________________________Distance to nearest: Well -.__--"_`-,' ___- Foundation -------- Property Line <br /> SEEPAGE PIT [ ] Depth ____________________ Diameter ---------------- Number --------- ------------------ Rock Filled Yes ❑ No ❑ �`' <br /> O <br /> Water Table Depth ------------------------------------------------Rock Size -------------------- --------- <br /> Distance to nearest; Well ________________________________________Foundation -------------------- Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ____________________________________________ Date --------------.._..._..___________) <br /> SepticTank (Specify Requirements) ------------------- ------------------------------------------------------------------------------------------------------------------------- <br /> DisposalField (Specify Requirements) ----------------------------------------------------------------•---------------------------------------------------- --------------- <br /> -------------------------------------------------------------------------------__:---------------------------------------------------------------------------------------------------------------------- <br /> (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 Son 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 ------- ------------- a Owner <br /> ---- f Title -------- - - <br /> ----------------------------------------------- <br /> (if r <br /> - -- ---------------------------------------------------- <br /> (If er than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY _.__ <br /> DATE <br /> BUILDINGPERMIT ISSUED -------------------------------------------------------------•-------------------------------------------DATE - --- -------•----------------------------- <br /> ADDITIONAL COMMENTS - <br /> ------------------ ------------------------------------------------------------------------------------------------------------------------------- --------------------------------------- -------------- <br /> ------------------------------------------------ -------- - - --------- --------------------------------- ---------------------------------------"-- <br /> ---------- <br /> _------------------------------ <br /> ____ 1_ ________-_ _ _ _ <br /> Final Inspection b �� 1 <br /> P Y <br /> -------------------- ------------ - -------------------- -_----.Date ---------------- <br /> SAN <br /> - ------------7 - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1•'68 Rev. 5M <br />