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F R;FeICI USE: <br /> J APPLICATION FOR SANITATION PERMIT <br /> -C %_V (Complete in Triplicate) Permit No. ----- <br /> --------- <br /> - <br /> ------------------------------- -i------------ � t This Permit Expires 1 Year From Date Issued , <br /> Date Issued­-�-.:� <br /> : ---7/ <br /> --------------- ---------- ---------------------------- <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 Count Or nce No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION -- - - --- ------ - ---------- ------CENSUS TRACT <br /> Owner's Name --------- - ----- --------------------- t-�-- ---_- Phone -----_ ------ <br /> Address ------------------ -- - - -------- - - ��� -------------------•--. City - ` / <br /> Contractor's Name ---- -� -----------------�-- ---------�-- License #f J Phone .. <br /> Installation will serve: Residence Apartment House❑ Commercial ❑Trailer Court ;❑ <br /> Motel ❑Other -------------------------------------------- <br /> 17) <br /> -----------7----------------------------- <br /> Number of living units:________ Number a roo s __`---�__Garbage Grinder �l_v_ Lot Size - -------------- <br /> Water Supply: Public System and name _ _____. 11��� ----------------------------•----------------- Private E]-- - - ------- <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt Clay ❑ Peat ] <br /> Loam ❑ Clay Loam E]Hardpan E] Adobe P----i(TMaterial _ 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 seepa pit permitted if pu 11c sewer is available within 200 feet, <br /> ��,y-� r' <br /> P CKAGE TREATMENT [ ] SEPTIC TANK'[ Size_--_____-"l l_________ _________ Liquid Depth -�---- <br /> Capacity __ U0.�'__-_ Type _U!_?_�'-___Ca,�Material t1Gr�,__ No. Compartments .._.__._.._ <br /> tance to nearest: Well ____-_ 0 <br /> -----------Foundation ------ Prop. Line <br /> •------- V <br /> __.-- Length of each line_ -4 -- Total Length .l_c��-_._._.....�+ <br /> LEACHING LINE No. of Lines ___ _ g ,J----- / 9 t" <br /> �l�,L, r% <br /> 'D` Box _ _ Type Filter Material��,;?_________- epth Filter.M7terial _ __________----------------------- <br /> Distance <br /> __ ______________�f <br /> Distance o nearest: Well ------------�_--_____ Foundation ---/__0 Property Line �______________Y.. Qr <br /> r <br /> SEEPAGE PIT [ Depth __;ate----- <br /> ---------- Diameter -------- Number ---------------------------- Rock Filled Yes 2----No <br /> Water Table Depth :. -......................Rock-Size <br /> Distance to nearest: Well -----------"- ------------Foundation /0------------ Prop. Line.:!�-------- -_-- <br /> -- <br /> REPAIR/ADDITION(Prev. Sanitation:Permit#I-------------------------------------------- Date ----------------------------------) <br /> Septic Tank(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 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 /> � _ _`" Title ------ - `- `( ---------------------------------- <br /> By (If the "an owner) <br /> FOR DEPARTMENT USE ONLY / <br /> APPLICATION ACCEPTED BY ------------------------------------------------. DATE --- y / ---------7------_---- <br /> BUILDING PERMIT ISSUED ------------------------------ ------------------------- ------- - __DATE --------- ----------------------------- <br /> - <br /> ADDITIONALCOMMENTS ------------------------------------------------------------------------------------------------------------------------ ------------------------------------- <br /> ------------------------------------------------------------------------------------------------------------------------ <br /> - <br /> ----------------------------------------------------- ---------- - - ------------------------------------------------------------------------------------------------------------------------------- <br /> � °=------- <br /> Final Inspection by 1Cr -------- ----------- -- -----------Date __9------------------ ='-------- <br /> SAN JO QUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />