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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit No. <br /> Date Issued _...... <br /> __-_--____-_ ---------------------------------- This Permit Expires 1 Year From Date Issued <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 } " _ �, _ _ __ 50 <br /> ___°___ ___ '_:_ _.� F s__ CENSUS TRACT __-_ �_ _._ <br /> } T �: .4� €, - Phone <br /> Owner's Name ------ ------ -- -------------•-- - - ,,--- <br /> Address _ _ ' ---=50----- ` ''f -------------------------------------- Cit r' " t` ' -° `='v <br /> Contractor's Name -----_ " ' _.License ------ -------------- Phone r_ `_:'_...� " f__r__ <br /> h s --- ------- -- --- - -- <br /> Installation will serve: Residence IM Apartment House-E] Commercial ❑Trailer Court i❑ <br /> Motel ❑Other ------------------------------------------- <br /> Number of living units:________ Number of bedrooms __'4'_._:_.Garbage Grinder _A-____ Lot Size _ :___ ' ........... <br /> Water Supply: Public System and name ----------------------------------- ---------------------- - -• -----Private <br /> Character of soil to a depth of 3 feet: Sand fN Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ AdobefT-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 ---._______---___---_____- 0 <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 /> Water Table Depth -----------------------------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well ----------------------------------------Foundation ____________________ Prop. Line -----------.......... <br /> REPAIR,/ADDITION(Prev. Sanitation Permit <br /> �7#' ______________J_________?______J_-_____________- Date ---------------------------------- <br /> Septic Tank (Specify Requirements) _______ ___________ __ __ __ _ _ _ <br /> Disposal Field (Specify Requirements) _____' f ' -- ----------------------------------------------------f/ ` t' --. - ' -- <br /> q r <br /> f i, kyr f i 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 _ ., s.......° � ° -- - ------ Owner <br /> -- - ---- - - - ---- <br /> BY ------- -�`---- x, y <br /> -- -------------- Title ------ <br /> (If other-t on,.owner) <br /> p FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -------------------- - -----------------------------------. DATE ----- 0_-17`•6�-----' <br /> BUILDING PERMIT ISSUED _______________ _DATE __--______._-_-______ --___-___-_.-_-_ <br /> ADDITIONALCOMMENTS ----------- - ---------- ------ ------------------------------------------------------------------------------------------ --------------------------- <br /> -------------------------------------- --- -- -- ----- --- - <br /> - - -- -- - ----------------------------------------------------- -- - - <br /> Final Inspection : ---- - -- -- ------ <br /> ----------Date --- -- ----------------- <br /> SAN <br /> --� <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT af5 <br /> r <br /> E. H. 9 1-'68 Rev. 5M <br />