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J;.�,40' FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> ----------------- Permit No.75-#� 3� <br /> (Complete in Triplicate) ------------ <br /> This Permit Expires 1 Year From Date Issued Date Issued -...--- --=73 <br /> ---------------- <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 <br /> JOB ADDRESS/LOCATION ate_ ri'- -- ';- ---------------------------------- .CENSUS TRACT --�"`3-__... <br /> ---- <br /> Owner's Name / z ----- -Phone --------------------­ <br /> -------------------------- ----------------- ----- City <br /> ------------ �a -----• <br /> Contractor's Name ------------1 ±- ----- --- ------ <br /> ------License License # Phone ----------------•-.--••------- <br /> Installation will serve: Residence �rtment House-E] Commercial ❑Trailer Court ❑ <br /> Motel ❑ Other ------- --------------- <br /> Number of living units:.-------- -- Number of bedrooms ------------Garbage Grinder ------------ Lot Size -------------_-__-_--_----__-----_--_ ... <br /> Water Supply: Public System and name ----------------------------------•------------•---------------------------------------------------------------Private <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ CI ❑ Peat F] Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan E] 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,) O <br /> PACKAGE TREATMENT [ I SEPTIC TANK'[ ] Size----------------------------- ------------------ Liquid Depth -----------.-------------- <br /> Capacity <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 --------------------._----____-_-_-_..._.__- (V <br /> Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line ---_--_-_-.-___ ----.__. r <br /> SEEPAGE PIT [ j 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 /> SepticTank (Specify Requirements) ------------- -- ----------------------------------s----------------------------------------------------- ---------------------------- <br /> Disposal <br /> ---- - - <br /> Disposal Field {Specify Requirements) G--CO '1 -� 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 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 Title - ------------------ <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY --- - -- -- ------------------------------------------------------------------------------- DATE --7'-3------------------ <br /> BUILDING PERMIT ISSUED ------------------------- --------------------------------------------------------------------------------DATE ------------- ------------- --------------- <br /> ADDITIONAL COMMENTS ----------------------------------------------------------------------------------------------------------------------------------- <br /> ------------------ ------------- --- _ - ----------------- --- ------ --- ---------------------- i� - --------- ----- <br /> ---- ---- -- --- - - ---------- - - - <br /> Final Inspection by: -------- `e,* --- ------------------ -.-Date-------------------------------------------------- <br /> ---------- <br /> . <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />