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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> --------------- -------- --------------- <br /> (Complete in Triplicate) Permit No. _7_x_... . ._. <br /> _________________________ _ This Permit Expires 1 Year From Date Issued Date Issued __$_:.�.�I:.7. L <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-_ ______ __ ___. _ <br /> _ ------ -------- ----------------- -- CENSUS TRACT -------------------------- <br /> ----------- <br /> Owner's Name --------- --- --- ----- ----------Phone <br /> -------------- - ------------ <br /> Address ----------------- r ---------- --- itY - - -- -------------------- / -------------------- <br /> Contractor's Name _________ ___ __ ------- ---e._._�@_.�License # -�--- L______ Phone <br /> Installation will serve: Residence Apartment House❑ Commercial ❑Trailer Court ;❑ <br /> Motel ❑Other -------------------------------------------- <br /> Number of living units: Number of bedrooms - Garbage Grinder - Lot Size 1--------------------------------- <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 <br /> [ ] SEPTIC TANK( Size.______�Jr__ ______________________ Liquid Depth __ __!___.__.._._._..._. N.. <br /> Capacity _ Type - �_ Material.__-r?'[ -%__ No. Compartments -__.�?"— ... b\ <br /> --- l 1_F_ r <br /> Distance to nearest: Well ___________�Q _______________Foundation _____LC2_ ____ Prop. Line ___.�__1......... �I <br /> i r <br /> LEACHING LINE V No. of Lines _______ . ----------- Length of eac line______FQ-- __-_____ Total Length .2'. .............. <br /> 'D' Box ___h/_ Type Filter Material ___ --------- "o <br /> Filter Material -----/�_!�........................... v <br /> el <br /> Distance to nearest: Well ____ - -----_____ Foundation ------------------------ Property Line -__-S- <br /> SEEPAGE PIT [ ] Depth _______ Diameter ----------------- Number ---------------------------- Rock Filled Yes 0 No i❑ <br /> Water TableDepth ------------------------------------ -----------Rock Size -------------------------------- <br /> Distance <br /> ----------•------ .-•----Distance to nearest: Well ________________________________________Foundation ----------_.-------- Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ____________________________________________ Date ________-_________________________1 <br /> SepticTank (Specify Requirements) ----- ------------------------------------------------------•-----------------------•------------•---.----------------------------- <br /> Disposal Field (Specify Requirements) ----------- ---------------------------------------------------------- ---------- <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 -f -�---,-------- Owner �',, <br /> BY --------' -- ------r <br /> ----- Title ---c�� - <br /> -- -- - -------------------------------- --- --- ------------------------------------------------------ <br /> (If o than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ______ _ __`____ ____ <br /> ----------------------------------------------------------------------- DATE -----"1---- -- Z <br /> ------,.---------- <br /> BUILDINGPERMIT ISSUED ---------------------------------------------------------------------------------------------------------DATE ------------------------------------------- <br /> ADDITIONAL COMMENTS <br /> __------------------------------------------------_-------_----------------------------------------------------------------------------------------------------------------------------------- <br /> __ft--------- <br /> ----------------------------------------------------------------------------------------______________________________________________________________________________________________________ _ <br /> _______________________________________________-_____ __ __ n _ _ _ - _ _ _ _ ___________________________________-_ _ ------ <br /> Final Inspection b -_-_---- <br /> -------------- --- --------------------- -- -- - - ---- ------ - --- ----- --- <br /> PY� ------------------------f-- - -- ---------------------------------------••---------------------------------------.Date -------- - - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />