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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION Oftj` <br /> ------------ L <br /> - - ----------------- dU I�(Complete in Triplicate) ermit Na. 72---_4 Z"_G-_8.5 <br /> This Permit Expires 7 Year From Date Issued <br /> --------=---------------------------------------------- <br /> Date Issued <br /> --------------------------------------------------------- <br /> Application is hereby made to the San Joaquin Local Health District 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 .__.5 1�® ---------------------------CENSUS TRACT ---,�---- ------- <br /> Owner's Name ---- C� -<<- -- - - -------------------------------------------------- ---------------Phone------- ---------------------------- <br /> Address ------------ Y-- -�/ City -- / ---------•------ <br /> Contractor's Name ----------- -------- _ ---------� , --.License # ` Phone ------------•-- --------- <br /> Installation will serve: Residence Apartment House°❑ Commercial []Trailer Court ;❑ <br /> Motel ❑Other -------------------------------------------- <br /> Number of living units:------ Number of bedrooms ___)__Garbage Grinder ------------ Lot Size ______0 ____-__- <br /> Water Supply: Public System and name ---------------------- ------------------------------------------------ -----------------------------Private Of <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat ❑ Sandy Loom jdJ 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,) <br /> PACKAGE TREATMENT { ] SEPTIC TANK:[ ] Size________________________________________________ Liquid Depth _____..____-______________ <br /> Capacity ---------- ------ Type -------------------- Material---------------------- No. Compartments --------------------- �41 <br /> Distance to nearest: Well ____________________________________Foundation ---------------------- Prop. Line ________---. --____-_ 0 <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 -------------------------- r <br /> Distance to nearest: Well ________________________________________Foundation -------------------- Prop. Line _____---._-._---_-_-__ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ____________________________________________ Date ______--________________________.-) <br /> Septic Tank (Specify Requirements) ------- --- --- ---------------------------------------------------------------I---------------------------- ----------------------------- <br /> Disposal <br /> ---- ----------------------------------------------------------------------- -•--------------------------- <br /> Disposal Field {Specify Requirements) ---- --- -- --- ---------- -"`' --------------------- <br /> -- --- --- - ---- <br /> x 1 �----------------- ----------------------------------- <br /> ---------- <br /> ------------------------------------------- <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 /> BY --------------------------------- ------t--------------- Title -------------------------------------------- <br /> -------------------------------- <br /> -- ----------- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY - ------- ---------------------------------------------- ----------- DATE ----------- <br /> BUILDING PERMIT ISSUED ---------------------------------------------------------------------------------------------------------DATE ------------------------------------------- <br /> ADDITIONALCOMMENTS ----------------------------------------------------------------------- ---------------------------------------------------------_----------•-------------- - <br /> ------------------------ ___ _--__-- ------_------------------- --------- -------- -------------------------------------------------- -- y <br /> -Final Inspection by: - ---- -- Date ------------------------------------------ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />