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FOR OFFICE USE: - x <br /> APPLICATION FOR SANITATION PERMIT <br /> --------------- - = _ Permit No: �/ ---` <br /> (Complete in Triplicate) <br /> -------------------------------- <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�rince No. 549 and existing Rules and Regulations: <br /> 3 / .--.CENSUS TRACT -" D....---- <br /> JOB ADDRESS/LOCATIO Q - -A---------- yY ` <br /> Owner's Name - ----- '�------- - - ---------------------------------------- ------------ -Phone -------------------------------- <br /> Address .-..----- - Y <br /> Cit ------- ----------- =---------- ------ <br /> -.License #Aj 3f;? Phone ------------- - - ---- ----- <br /> i Contractor's Name ----- �1J - m- <br /> F Installation will serve: Residence Apartrrierit,House❑'Commercial e❑Trailer-Court •;[] <br /> Motel ❑Other - '`- ------------------------ - - . <br /> Number of living units:-------I--- Number of bedrooms 6-,;Z-----Garbage Grinder ___. 1', •ot-Sizj. .E_.--` --7------------------- •_' <br /> Water Supply: Public System and name ---------------=------•-------- ------------------------ "'----------- ------ -----------,-- Private <br /> j Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam I Clay Loam:❑ <br /> f Hardpan []`Adobe'❑Fill Material ------------ If yes, type ---------------------------- <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc^r,'must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted-if public sewer is available within 200 feet,) Ilk <br /> PACKAGE TREATMENT [ ] SEPTIC TANK'[ ]` -- - q p <br /> ,f ' Size [ Li uid Det Ll <br /> Capacity -----f Type ------------�w---- Material---------------------- No. Compartments ------ -----•-------- <br /> Distance to nearest: Well ----------------------I-------�-Foundation ----------------------- Prop. Line ----------------------- <br /> I __..- f <br /> LEACHING LINE [ ] No. of Lines ----__-- .- Length—of each-)line------------------------------ 7ot-al Length ----------------_--------- <br /> ' Type ---------'---------.De al --------------------------------------- <br /> D' Box .---._.-_.__ 7 e Filter Material Depth Filter Material <br /> Distance to nearest: Well ----------------__---- Foundation -----------________--- Property Line ----_--.--------..._._-- <br /> i � <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number ----------------------------)Rock Filled Yes C]] No i❑ <br /> Water Tabled Depth -------------- -----------------------I-=--------Rock Size --------------------------------- <br /> Distance <br /> ---_--------------- ------ <br /> ` Distance to nearest: Well ----------------------------- -------- -Foundation _-_--------,------- Prop. Line -------------.-_--__.. <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------- --------------------#------ Date ------ .__-_ - ------- <br /> ----------- <br /> ----- f l <br /> Septic Tank (Specify Requirements) __ ---._- <br /> --------- ---- ----- -- ------- <br /> ----- -- -- - -- <br /> Disposal Field (Specify Requirements) - -------- ------ - - - ----- ------- -, ------------ <br /> 1 ---------------------------------------------------------------------`----------------------- <br /> -------------------------------- 1 <br /> - -------------(Draw existing and required <br /> ------------------------------------------- - - - <br /> ------------------------------- ------------------------:------------------------------------- <br /> 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 /> i as to become Wect to Workman's Co nsati.on laws o�'California.. _ � <br /> Signed r <br /> g ------ . ----- <br /> Owner <br /> �- <br /> BY =' --------�------.,TiNe�__ <br /> (If other than owner) �).��; <br /> -1d4t'r-------------- ------- ----- <br /> x_11__ "'F0V PE JAYTAEN-V,USE ONLY <br /> APPLICATION ACCEPTED BY ---------- ' ____ ----------------------------- DAT == F ------ <br /> BUILDING PERMIT ISSUED ------------------- --- ---------------------------- �L DATE --------------------------------------------------------------------- -- <br /> ADDITIONALCOMMENTS ------------ ------------------- ----------------------- % - ----- ---------=------------- ------------ <br /> ------------------------ ------------------------------------- ---- ------------------- <br /> ---------- <br /> _ r._ - `� -------- <br /> Final Inspection by: -- - '�-- '--------------------- -------- <br /> - --- ------------------------------------Date -----�--------------------- ------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />