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t, <br /> - FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> --------------------------------------- - �------ <br /> 3 . <br /> tI`� (Complete in Triplicate) Permit No. __ <br /> This Permit Expires 1 Year From Date Issued Date Issued _.�_ZF :i 0 <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/LOCATI N .__�_� _,--_-�7// j 'f? ----( - ------------------------------CENSUS TRACT ------------------.-.----- <br /> Owner's Name �� <br /> - e„S------hAt -- -------/;A4C4 ------------------- -------------------Phone ------------------------------------ <br /> Address — --b- -------' -�------------------------------------•--. City /- INp--------------------------------------------------- <br /> Contractor's Name -------------------------------------------------------------------------------------.License #q2y e---- Phone ---------------- ------------- <br /> Installation will serve: Residence g Apartment 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'NI 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 /> W <br /> Capacity ------------------- Type ----- ------------- Material---------------------- No. Compartments ------_------------- <br /> Distance to nearest: Well ----- ----________________________Foundation ---------------------- Prop. Line __._--_-__.________--- O <br /> LEACHING LINE [ ] No. of Lines --------- -------------- L ngth of each line---------------------------- Total Length ___________________________ <br /> 'D' Box ___---_---- Type Filter M terial ___________________Depth Filter Material _-_________________________________________ <br /> Distance to nearest: Well _____ _________________ Foundation ------------------------ Property Line _---_____.________---___ <br /> SEEPAGE PIT [ ] Depth --- ---------------- Diamete ----------------- Number -__---------_-_-__---_____ Rock Filled Yes '❑ No iQ <br /> Water Table Depth -------------- ----------=----------------------Rock Size -------------------------------- <br /> Distance to nearest: Well __ __ ___ ______________________________Foundation -------------------- Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -______----_,_,-_,__-_ _____--___-_ Date ----------------------------------) ,� 0.- <br /> Septic Tank (Specify Requirements) -------�g�l./�----------- 'v 1Y/_'------ `��'e-- �_ _--_ e <br /> Disposal Field (Specify Requirements) """�< -��Q.__-_- Z;f ----- ---------------- "�`'�------- ------------ <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 /> 7 <br /> Signed ---- 65: --- ---- -------- - Owner <br /> Title -------------------------------------------------------- ------------ <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ----- L VC,SN _ - -------------------- DATE - r7 --R----------- <br /> BUILDING PERMIT ISSUED ------------------------- ----------- T` -------------------------------------------- DATE <br /> ADDITIONALCOMMENTS ------------------------------------ ---------------------- ----------------------------------- ------ --------------------------------------------------------- <br /> --------------------------------------------- <br /> - ------------------------------------------------------------------------------------------------------------------------------------ <br /> Final Inspection by e ---�� ------------------------------------------ ------ --------- Date S=-6�-r?------------ --------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />