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FOR OFFICE USE: <br /> .................................... 0APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit No. .... .:3 . <br /> ..................................................... �This Permit Expires 1 Year From Date Issued <br /> 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 application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION ,.../��� - ... ',... : �.. ja 1. .........CENSUS TRAGI' .......................... <br /> Owner's Name ........ J`f�. ................ .....__.........:........._...........Phone ........................... <br /> Address --------------- -, . .............. . ..............................._--•••--•--....... City . .1 ............................................. <br /> Contractor's Name ....1.er.z.-r-- " f v17e,..,,, ...............................License Phone <br /> Installation will serve: Residence J$Apartment House❑ Commercial [3Trailer Court C] <br /> Motel ❑Other ............................................ <br /> Number of living units:........ Number of bedrooms _.......Garbage Grinder &.0... Lot Size ................. <br /> Water Supply: Public System and name ..._ �? �/C-.-%!✓4r,rl"---•� f alt N-£.-••••-•.•..............................Private ❑ <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam 0 Clay Loam ❑ <br /> Hardpan❑ Adobe 0 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 i ] Size........................................ liquid Depth .................................. <br /> Capacity Type Material...................... No. Compartments .............. <br /> Distance to nearest: Well ....................................Foundation ...................... Prop. Line ......................W <br /> LEACHING LINE [ j No. of Lines ........................ Length of each line............................. Total Length ............................ to <br /> 'D' Box ............ Type Filter Material ....................Depth Filter Material ............................................ <br /> Distance to nearest: Well ........................ Foundation ........................ Property Line .........................Y <br /> SEEPAGE PIT ( ) Depth .................... Diameter Number ............................ Rock Filled Yes ❑ No ❑pw <br /> Water Table Depth .......Rock Size <br /> Distance to nearest: Well .Foundation .................... Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# .......................................... Date ..................................) <br /> Septic Tank (Specify Requirements) XePe.0,e:-e,./-.lc-'aie;...:-611-/ZZ.....aw.. ,� �1��" ? •-e-t r4i*�lw <br /> DisposalField (Specify Requirements) .......-----•------•------------------------------------------------•-----•-•-••-•------•-•--------••--...•--................-•-•--. <br /> -•-•----•- ............................................................................................................................................................................................... <br /> ..........................---............... ..........._..............................................._............................................................................................ <br /> (Draw existing and required addition on reverse side) <br /> 1 hereby certify that 1 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 /> "1 certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed ----------------------- ..............0- <br /> .... i.. Owner <br /> By �� -... . Title . l h til�. .......................................... <br /> (If er than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY .. ....-•----•............................................................... DATE ..... .. ... ....�.._............. <br /> BUILDING PERMIT ISSUED ..............DATE ..... .................................... <br /> ADDITIONALCOMMENTS .................................................................._...........................---.................................:.._......_................. <br /> ........................ --•...........................................................................••-•---......:--•--.........................--•---............._........._............_............ <br /> ............. <br /> ................. <br /> -•---••-------...................... <br /> .. ............................................................................... . ................ <br /> ... <br /> .................... <br /> ........................ <br /> ...... <br /> .................... <br /> .................. <br /> Final Inspection by: ..... . Date ...._ .. .. " ?.. .........._. <br /> SAN JOAQUIN LOCAL HEALTHDISTRICT a, <br /> E. H.13 241-'68 Rev. 5M ` 7/72 3 M <br />