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FOR OFFICE USE: ` <br /> APPLICATION FOR SANITATION PERMIT <br /> ........ ...................................... Permit No. . .33 <br /> (Complete in Triplicate) <br /> ..................... This Permit Expires 1 Year From Dote Issued Date Issued <br /> Application is hereby made to the San .Joaquin Local Health Districf for a per 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 ...... ------- 75 - ....... _-•-__ <br /> - --- .........CENSUS TRACT <br /> ............, ---- ;._.._._...._ <br /> LFZr42Owner's Name . _ o --- ............ .Phonete ... <br /> ...... <br /> Address - _ .... Cit .._ ---------- ................................... <br /> r <br /> Contractor's Name _-• f ; R:4 ._ ._S ?!us 4��:.............License #-Z -` •---. Phone .q.jG6.F:.`...�a.7...... <br /> Installation will serve: I Residence ,Apartment House Commercial []Trailer Court ❑ <br /> Motel ❑Other ............................................ _ <br /> Number of living units:.___ I_- Number of bedrooms _e�.__...Garbage Grinder ............ Lot Size <br /> -- - --- ------------------- <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 ❑ 3 ' <br /> Hardpan ❑ Adobe.1 Fill Material _-__..____-_ If yes,type ___-__.-_._______11__._..__._ <br /> f ,. <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-availEabl"e within 200 feetJ <br /> PACKAGE TREATMENT .[ ] SEPTIC TANK[ ] Size..................................-.------------ Liquid Depth --.._....... ------------- <br /> Capacity p city ----------=--------- Type .................... Material-----------------..... No. Compartments ...................... <br /> Distance to nearest: Well <br /> .........:.....::......:_._....::.Foundation ....------••- ... Prop'. Line ................. <br /> LEACHING LINE [ ] No. of Lines ...__-__F---- - - Length of each line----...._..._..l_..-_...__.. Total Length ............................ <br /> 'D' Box ........ --. Type Filter Material .. .:.:...:.}=-....Depth Filter Material ............................................ <br /> Distance to nearest: Well ....................... Foundation ......... Property Line ........................... <br /> SEEPAGE PIT [ ) Depth --------------�--'- Diam'eter—............... Number .--_.-------f.._.._..___.... Rock Filled Yes 0 No fi] <br /> i <br /> Water Table!Depth: _–�— . Rock Sizer <br /> Distance fo`r Barest: Well .............. ...Foundation ....... Prop. line ' <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ............................................ Date ..................................) <br /> Septic Tank (Specify Requirements) --••................ _- <br /> .............. <br /> Disposal Field (Specify Requirements) ..... --------------------------------------------------------- <br /> '.............. .............. ----------- ................I..................... <br /> ------------------------------------------------------------------------------------------•------------- ----------------------------------------------------------------•-•-------••-•-•---••--------- <br /> f (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 Mules and Regulations of the San Joaquin Local Health District. Home owner or Ilcen- <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." i <br /> Signed . '--- -.._.... Own <br /> ... <br /> BY <br /> (If other than owner) I <br /> _ FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ....... <br /> BUILDING PERMIT ISSUED ..............4-iDATE i <br /> ADDITIONALCOMMENTS ......................•...................................................................................................................... ------ <br /> i <br /> ................•----•---•---'...................:--•---.....-----------------------------------------------------------------------------•-----------=------------------------------------------••------- <br /> .. ... .............. ............... ---------- ........... ... .. . . <br /> ............................................ .. .. rY ,.. ............ ......_. <br /> _. <br /> Final Inspection by: -------•------- = -•� - �--- = - . . ..........:........:..�:...... <br /> -..---=..........................Date.--... `°r!'.:............ ............ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H.13 24 1-'68 Rev. 5M 7172 3 i� <br />