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- r-0R OFFICE USE: 1,, � APPLICATION FOR SANITATION PERMIT <br /> +� <br /> (Complete in Trip illiate) Permit No. <br /> --------- --------------------------------------------- <br /> --------------------------------------------------------- This Permit Expires 1 Year From Date Issued Date Issued/-�__--zy_7-z <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 . r�b ----- ------------------ ------------------CENSUS TRACT ---.----d-------'----�- <br /> ` - <br /> r- <br /> ---__--__PhoneOwner's Name ------- <br /> Address ---- --------------- ---- -4;0- -S------ carY <br /> Contractor's Name ___________ —------------------- #/ �1_____ Phone T �T_��6�. .. <br /> Installation will serve: Residence Apartment House,❑ Commercial ❑Trailer Court !❑ <br /> Motel ❑Other -------------------------------------------- <br /> Number <br /> ------ --- ------ <br /> Number of living units:_---F------ Number of bedrooms -__�''_'_�_'_'__Garbage Grinder ------------ Lot Size l'f� x u ................ <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 f ] Size-----------------------------------.------------ Liquid Depth -______--___---._____-. <br /> Capacity -------------------- Type -------------------- Material---------------------- No. Compartments ...................... <br /> Distance to nearest: Well ______---.__:_._-_________________Foundation ---------------------- Prop. Line ...................... <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: Well --------------- -------- Foundation ------------------------ Property Line -----------------------_ <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ________________ Number ---------------------------.- Rock Filled Yes '❑ No i❑ <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) ---------------------------- --------------------------------------------- - - <br /> r � <br /> Disposal Field (Specify Requirements) --------- � ----------�Q ----------------------- - <br /> ----------- --------------------------------------------------------------- <br /> -e---- 3" X S-- ----- - ---V-A <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 ------------lothhan <br /> -------- ---------------- --------- ----- Owner <br /> --`----- Title ------ <br /> BY --- <br /> ( owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCE TED BY -� ------ ------ -- --�--------------------------------------------- DATE -- <br /> BUILDING PERMIT ISSUED ----- -- ----------------------------------------------------------DATE - ---------------------------------------- <br /> ADDITIONALCOMMENTS -------------- ------------------------------------------------------------------------------------------------------ -------- ---- --------------- ----------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> -------------------------------------------------- ------------ <br /> -------------------------------------------- - ----- -- ---- ------- -- ---- -- ----- ---------- ---- - --- <br /> - ------------------------------------------------ - <br /> Final Inspection by Date 42 ��r �' J <br /> SA J AQUIIv LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />