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FOR OFFICE USE:y <br /> ------------------------------------- <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit No. ._.__ -_. __ __, <br /> ( `� This Permit Expires 1 Year From Date Issued Date Issued _-3_a_-�'' <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 ---- <br /> JOB ADDRESS/LOCA ION ___l_-_7_�__.__ __.� ____ __._ _�I2/���'-____���-1----CENSUS TRACT ___-----------�/ <br /> Owner's Name � �1(- � n� -------Phone Q.�"�.t.- �-: - <br /> Address __ _ _____ \ ,--� q ��----- - <br /> _ <br /> -7--��---�---�--'`-_C.�/�'_�� /��f�--------------------- city ---- -.p� g �/ <br /> Contractor's Name ___-_ �-�.._.___ f ________ ./_l__ --------------------------License A1413Y ----- Phone �T .. _u.. <br /> Installation will serve: Residence Apartment House,V Commercial ❑Trailer Court !Q <br /> Motel ❑Other -------------------------------------------- <br /> Number of living units:__------ Number of bedrooms 3-------Garbage Grinder ------------ Lot Size --_-_._-___--------------------------•---- <br /> Water Supply: Public System and name ----------------------------------------------------------------------------------•-------- ------Private <br /> Character of soil to a depth of 3 feet: Sand'fX Silt❑ Clay ❑ Peat❑ Sandy Loam Q 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 p rmitted if public sewer is available within 200 feet,) v <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size------------------------------------------------ Liquid Depth _____-_..___-___---__-___- <br /> CapacitY -------------------- Type ---- --------------- Mat r al--------------------- No. Compartments -..................... �h <br /> Distance to nearest: Well ___ _________________________ _____Foundation ---------------------- Prop. Line ...................... ` <br /> LEACHING LINE [ ] No. of Lines ength of eachline---------------------------- Total Length <br /> 'D' Box ____-__._-- Type Filter aterial __________ _________Depth Filter Material -_-__-____-_________._--___-___--.-_..._---- <br /> Distance to nearest: Well ___ ____________________ F undation ------------------------ Property Line ---------------------_- <br /> SEEPAGE <br /> _.•_-_-________--.-- __SEEPAGE PIT [ ] Depth -------------------- Diam er ________________ umber ----------------- ---------- Rock Filled Yes Q No 0 <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 /> D,�is.�osal Field (Specify Requireme ) -: ______/_ - __ <br /> ..... . <br /> --------------------------------------------------------------------------------------------------------------- - <br /> -----------------------ty----------------- ----------------------------------------- --------------------------------------------------------------------------- .-------------- <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that 1 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, 1 shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed --- ----- ------ ------------- - -------------------------- ---------------- Owner <br /> C�_� Title ----- ------ -- <br /> ---- ---- --- `� --------------- <br /> (If other than owner) <br /> -en 43 FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY _________ __ __.-____ _ __ ______ <br /> ------------------------------ ---------------- DATE -- -7- S- --- '2-------- <br /> BUILDING PERMIT ISSUED -------------------------------------------------------------------------- ---------------------DATE <br /> ADDITIONALCOMMENTS --------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ---------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------------------------ <br /> ------------------------------------------ --- - - _ <br /> --------------------------------------- ------ ----------------------------- --- -- - - -- <br /> Final Inspection by: - Date ----------- <br /> ---------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />