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FOR OFFICE USE: <br /> /� ' APPLICATION FOR SANITATION PERMIT <br /> --zle ------- , <br /> �� Permit No. �---- <br /> ----------- <br /> _ <br /> (Complete in Triplicate) <br /> -------- -.. --------------------------------------- <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 ---------� <br /> _ Ql(o �Ge __._____________CENSUS TRACT --------------__ <br /> / ` ' r�' 1 <br /> Owner's NameCGX A---- --mom`-�-------- -- -------------------Phone <br /> Address --------------------- ' ----------------- ---------------- ....... City ---------------------------------------------L-f----�----------- -------------- <br /> # lQ ---- PhoneContractor's Name ---__ - -___4c - --��� <br /> Installation will serve: ResidenceApartment House❑ 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 ❑ 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 [ ] Size-----------------------------------.------------ Liquid Depth __________________________ O <br /> Capacity -------------------- Type -------------------- Material--------------------- No, Compartments ...................... <br /> Distance to nearest: Well _______________________________Foundation? _:___________________ Prop. Line -_--___-_-_--_-_...... <br /> LEACHING LINE [ ] No. of Lines ______ _ <br /> _________ _____ ,t-ength of .each line-__------------- _ ______ Total Length ---------______._______._... <br /> 'D' Box ----------._ Type Filter Material ________ ________Depth Filter Material <br /> Distance to nearest: Well ___________-__:____ Foundat!pn------------------------- Property Line ---_------.......,...... <br /> SEEPAGE PIT [ ] Depth _ _____ Diameter ________________ Numb _ ----------------------- Rock Filled Yes 0 No 0 <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 /> Disposal Field (Specify Requi ements) -----------------4;___ ._.---____ <br /> ---------------------------------------- ------ ------------- <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 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 /> ^ <br /> BY - t ---- ------ Title -------'r---- ---------- -------------- -------------------- <br /> (If of r han owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY - ------------------- <br /> -------- DATE l z <br /> BUILDING PERMIT ISSUED ------------------------------------------------------------------------------ -- <br /> ------ -------------DATE ------------------------------------------- <br /> ADDITIONALCOMMENTS ------------------------------------------------------------ --------------------------- --------------------------------------------- ----------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ------------------------------------------ ---------------------------------------------------------------------------------------------------------------------------- - <br /> -- ----------- <br /> -------------------------------------- - <br /> - - - - - - - - - - - ---- <br /> - -- --- --------------------------------------- - - ----------- - ---- -- --- ----- -- -- -- <br /> Final Inspection by: = --------------------------------- Date _/�Z�la --------- <br /> SAN JOAQUIN* LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />