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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT � � <br /> --------------- --- -------- ------------ ScAJ <br /> (Complete in Triplicate] Rer-rxyit o_ _ __ _________________ t <br /> --------------------------------_----------- -_------ This Permit Expires i 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 -�� -Q -----�Il. P6"_%1--------- ---- ----CENSUS TRACT -------------- <br /> Owner's Name --- e-------�°�'`-�'&41��< = �f Phone <br /> Address # =e----- -.'-- ----------------------------------------------- 1 �f �-- ------------------------------------•-- <br /> -"�.---�.-City,,. _,._,-.._.._ <br /> 4 Phone --------------------------- <br /> Contractor's Name - __-_-- e -�< � --------------------- License # � jC�<� f <br /> Installation will serJe: ResidenceXApartment House❑ Commercial :❑Trailer Court '.❑ <br /> Motel ❑ Other ---------------------- --------------------- <br /> Number of living units:---- Number of bedrooms -.3------Garb�age.Gr.indec, �0,_.Lot Size.._ ___�---C��/"��"_______________ <br /> Water Supply: Public System and name ----------------------------------------------------------- ------------------------------------------------Private <br /> Cha d'ter of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay 0 Peat❑ Sandy Loam ❑ Clay Loam ` <br /> Hardpan Adobe ❑ Fill Material ------------ If yes,type -------- --------- <br /> t �- <br /> (Ploo"t'I lan, showing; size of lot, location of system in relation to wells, buildings, etc. must�be placed on reverse side.) <br /> s I r <br /> NEW IN,STALLATl6N:- '(No septic tank or seepage pit permitted if public sewer is available within,tf 200 feet,) 5 <br /> PACKAGE TREATMENT [ I SEPTIC TANK'[ ] Size--------- ------------------------------- ----- Liquid'Depth -------------------------- <br /> ' tS <br /> Capacity - Type -------------------- Material-------------_ _ ----_ No. Compartments ---------_-------_-__. r <br /> I Ju <br /> I� r Distance to nearest: Well ------------------------------i_-_---.Foundation _._ ----- Prop. Line .---_________________ D <br /> ) <br /> LEACHING LINE F [!] No. of Lines _______________________ Length of eachline -___------ -_ Total Length __________.-------.:-...... r <br /> 'D' Box Type Filter Material _____________ ______Depth Filter Material --------------------._-___________________ t <br /> • <br /> Distance to nearest: Well ------------------------ Foundation _______ ---------------- Property Line -_-_______ <br /> SEEPAGE PIT [ Depth -------------------- Diameter ---- _�Number ---------------------------- Rock Filled Yes ❑ No i❑ <br /> t Wafter Table Depth <br /> -- - Rock Size <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ----------------. --- � <br /> REPAIR/ADDITION(Prev, Sanitation.Permit# --------------------------- <br /> y ----------------__ Date -------------------------------=--)��..� <br /> SepticTank (Specify Requiremen'ts) ---------------------------------------------------------------------------------------------------------- ._---------------------------� <br /> Disposal Field (Specify4Requirements) <br /> ---------- ---- -------------------------------- -- ------ <br /> (Drawexisting and required addition on reverse side) `4 <br /> I hereby certify that I have prepared this applicat of n and that the 'work will be done in accordance with Son 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: I <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 /> B -------------------------- <br /> - <br /> - - --- - - ---------------- Title _.. <br /> Y -- ------------------------- � � ` <br /> (If of t an owner) <br /> Xr <br /> .FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY --- - ----- ----- ----------------------- -- DATE 1L'--- - --7_C'_____-----. <br /> BUILDING PERMIT ISSUED ------------------- -- ` ---DATE ------- ----------------------------------- <br /> ADDITIONALCOMMENTS ----------------------------------------i------------------------------------------------ ----I--- ----------------------------------------------- ---------- <br /> --------------------F'-------------------------------- <br /> -------------------------------------------------- ------------------------------- --------------------------------- '---------- -------------------- -- I- - <br /> --------------------------------------- -- - -- - <br /> Final Inspection by: .- -------------------------------- --------------------------Date if`- ------ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'66 Rev. 5M •�' '�'' <br />