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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> --------------------------------------------_-- <br /> y <br /> Permit No. --��--- ---J. <br /> (Complete in Triplicate) <br /> ____--_-------_---------------------- This Permit Expires 1 Year From Date Issued Date Issued .-(p- -h'-Td <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 Ordinanc No. 549 and existing Rules and Regulations: <br /> Coee <br /> JOB ADDRESS/LOC TION �/�V.--- -- ------Q ,f=� ' v-� ---------------------CENSUS TRACT <br /> I�Q ' ~ � a <br /> Owner's Name h'' /7. /1�------- ------ -- A---------------------------------------------- Phone <br /> Address a7-©-9-16- -- S�- --------------------------------- City .PIV 1101?------------------------------------------------•-- <br /> Contractor's Name -License #r3Q� -.-- Phone .O.- - <br /> Installation will serve: Residence ®Apartment House❑ Commercial ❑Trailer Court ;❑ <br /> Motel ❑Other -------------- --- ------------------------ <br /> Number of living units:-_........ Number of bedrooms _,3-_----Garbage Grinder ------------ Lot Size /_- ----------E'-- - ------ <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,) 0 <br /> PACKAGE TREATMENT [ ] SEPTIC TANK.[ ] Size-------------------------------------_-.------- Liquid Depth ------------ ------------ <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 i❑ <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 /> Disposal Field (Specify Requirements) -------------------------------------------------------------------- --------- --------- ----------------------- <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 _- Owner <br /> ®r, <br /> BY ------ - Title ---------------------------------------------------------------------- <br /> {If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED 13Y ..-_ --- - ---------------------------- -- . DATE - �7�/G-9- <br /> --- - - - --- -- ------------------------------ <br /> BUILDING PERMIT ISSUED ---------------------------------------------------------------------- ------------------------------ ---DATE ------------ - ------------- ---------- <br /> ADDITIONALCOMMENTS - --- ---- ---- ---------------------------------------------------------------- --- ---------------------- ------=----------•---------------- <br /> ---------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------_ <br /> ---------------------------------------------------------------------------------------------------------------------- ----------------------------------------------- <br /> ------------ <br /> Final Inspection b Dafie ---- ------------__---------. ---------_- <br /> P Y ---- - ------------------------------------------------------------------ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />