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y <br /> FOR OFFICE `USSEE: PP`ICATION FOR SANITATION PERMIT p <br /> ` � �1 Permit No. <br /> !17 (Complete in Triplicate) <br /> -------- -------------------- ---yam � <br /> This Permit Expires 1 Year From Date Issued Date Issued <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 County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION ----------- L ,-=------ - - - 7 ----------- --------CENSUS TRACT ------�-Z........ <br /> Owner's Name -----------/---------- ------ T---------- - - ----------------------------------------- ------ -- --Phone ------------------------------------ <br /> Address --------------f �0- - -0�--------- --------- t--------- ........ City -- - <br /> Contractor's Name .. - --------- - �'__- _-_----- License # - - ��-_ Phone -T`!7`-1���•. <br /> Installation will serve: Residence Apartment House❑ Commercial ❑Trailer Court ❑ <br /> Motel ❑Other -------------------------------------------- <br /> Number <br /> ------------------------------- -- -- -Number of living units:-----1------ Number of bedrooms ____YGarbage Grinder -_ _ --_- - t Size __ -�_- __f$ _____________ <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 _________________________ <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 0 <br /> WaterTable Depth ------------------------------------------------Rock Size ------------------------------- <br /> Distance to nearest: Well ________________________________________Foundation -------------------- Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ____ ___ -------------------- Date --_-� -:�� ------ <br /> ) <br /> Septic Tank (Specify Requirements) --------------- - -- <br /> ---------------------- --- - <br /> Disposal Field (Specify Requirements) ----------------ez - --------7--0 &4,a4------•----------- --------------- <br /> --------------------------------------------------- ---------------------------7_ ��`-�------�/----------------------------------------------------- <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 -- r <br /> By --------------------------------------- -- a in ------------------------ ------------------------ -------------- ---------- <br /> (If other th ner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY --- --- ---------- - --- - --------------------------- DATE --------- ----------- <br /> BUILDING PERMIT ISSUED ---- ------------------------- - - --DATE <br /> ADDITIONALCOMMENTS ----------------------------------------------------- ------------------------------------------------------------------------------------- ----------------- <br /> ------------------------------------------------------------------------- ------- ----------------------------------------------------------------------------------------------------------------- <br /> ---------------------------------------------------------------- ------ <br /> - - ------------------------------------------- <br /> ------------- --- <br /> - -- ------ - - - - ----- <br /> Final Inspection by: ------------------ -- --- ------ =------ -- -- ----- z' Date �--� <br /> � - <br /> SAN JOAQUIN LOC HEALTH DISTRICT i <br /> E. H. 9 1-'68 Rev. 5M <br />