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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> .............I---- ----------------------------- Permit No. 1-2_`_.5_1-3 <br /> (Complete in Triplicate) <br /> ------------------- This Permit Expires 1 Year From Date Issued 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 -�So__----— _----- a ---------------------------------------------- ----CENSUS TRACT __5-4--1-------------- <br /> Owner's Name -------------------------------------------------------------------Phone ------------------------------------ <br /> Address ---- -- ------ X, _e_ --- ---- Cit <br /> Contractor's Name ___ -ems__ ___ r . -_.___.License # lg -y- Phone ______________________________ <br /> Installation will serve: Residence 0 Apartment House❑ Commercial ❑Trailer Court <br /> Motel ❑Other -------------------------------------------- <br /> Number of living units:___________ Number of bedrooms .....3.-..Garbage Grinder _--______.__ Loi Size --- <br /> Number <br /> Water Supply: Public System and name --------------------------------------------------------------------------------------------------------------Private m <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan W Adobe ❑ Fill Material ___________ If yes, type ____________________________ r <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,J <br /> PACKAGE TREATMENT [ I SEPTIC TANK f ] Size------------------------------------------------ Liquid Depth ---•---------------------- 0 <br /> Capacity - ---- - ---------- Type -------------------- Material---------------------- No. Compartments -----------........... <br /> Distance to nearest: Well _ __ __________________________Foundation -_.------------------- Prop. Line ________-_------___--_ Q <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 _-_________________-___ Lt <br /> SEEPAGE PIT [ } Depth ____________________ Diameter ---------------- Number .--------------------------- Rock Filled Yes ❑ No ❑ <br /> Water Table Depth ---------------------------------------_........Rock Size -------------------------------- <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ---------------------- 4 <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) <br /> SepticTank (Specify Requirements) -------------------------------------------------------------------------------------------------------------------------------------•--•--- <br /> Disposal Field (Specify Requirements) __ _ 5 _.... <br /> 3 • X2S ' r <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 Son Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the Son 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 - Title r ------------------------------- <br /> (If other than owner[ <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTEQBY --------------------------------------------------------- ----. DATE _.'> —� b- Y-------------- <br /> BUILDING PERMIT ISSUED -- ---------------------------------------------------------------------- ---- -------------- ------ --DATE ------------------------------------------- <br /> ADDITIONALCOMMENTS ---------------------------------------------------------------------------------------------------------------------------------•=--------------------- ----- <br /> ------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------ - ' -------- <br /> i <br /> ---------------------------- - ------------------------------------- ------------------------------------------------------------------------------ ------- <br /> Final Inspection by: ---------------------------------------Date,r7n,1.4- ---- -- -------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />