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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) <br /> Permit No. <br /> ---------=------------- ------------------------------- <br /> E Date Issued —---_-- <br /> -----------------_---------------------_-------- ------ This Permit Expires 1 Year From Date Issued <br /> # ZOe- 4:770-3 1 <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 /> __ LCENSUS TRACT --.__-_----------------------------------- <br /> -ADDRESS/LOCATION ._ _ w ? 0,------ ---'�Dv/- - -----N-- --- D�2AG -� <br /> Owner's Name / Gdd-----� {"� � �----- Phone <br /> Address /aZ/ 1- :Uv1. ��/ !T/��=G°' <br /> City 1e_n <br /> --- --------- ------------------------------------------------- <br /> Contractor's Name __-_ _ <br /> -----------------------�Z ' <br /> __.License # ---------------- Phone � �� <br /> Installation will serve: Residence Apartment House Commercial :ElTrailer Court <br /> Motel ❑Other -------------------------------------------- <br /> Number of living units:---- ----- Number of bedrooms >__ __Garbage Grinder __________ Lot Size __._____________________._________-_______- <br /> WaterSupply: Public System and name --------------------------------------------- ----------------------------------------------------------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand'® Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam ❑ <br /> I <br /> # Hardpan ❑ Adobe ❑ Fill Material ------------ If yes, type ---------------_____________ <br /> (P!'ot 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 ttank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK'f ] Si e_____________________ _ . Liquid Depth -- <br /> Capacity ---------'Type ------------ ------- Material--- -------- --------- No. Compartments ------ ----------- <br /> 1 <br /> Distance fo nearest: Wel! ---------- ------------------------F undation ---------------------- Prop. Line ..-__.-_... ....... <br /> LEACHING LINE [ ] No. of Lines ---------_______________ Len th of each line -_---- __ ------ Total Length ___________,_______-______•- <br /> 'D' Box ------------- Type Filter M erial __________________ _Depth Filter Material ------------------------------------.-____._ <br /> Distance to nearest: Well ----- ------------------ Faun ation ----------------------- Property Line -----•--_-----_------ <br /> SEEPAGE PIT [ ] Depth ---- - Diame r _______________ Nu ber ___-_______._-___._____ Rock Filled Yes ❑ No ,❑ <br /> E <br /> Water Table Depth _ __._ _ ----__Rock Size _________________________ ______ <br /> -------------------------- --- <br /> Distance to nearest:;Well ------------------------- <br /> -- -----------Foundation _---------------- Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# __-__ _ __________II_.________ Date _________________________________) <br /> Septic Tank (Specify Requirements) _______________ ___________________ !- <br /> Disposal Field (Specify Requirel}ments) ________________________________ _______ - <br /> ----------------------- --- { <br /> - -------------- - <br /> -._ /5 / T/ {� --------� ---------------------------------------------------------------------- <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 Wor man's Compensation laws of California." <br /> Signed -------- - -------- --- Owner <br /> -------------------- -- - - <br /> By ------ Title ------------- -- ---------------------------------------------------- <br /> Z(If other than owner) <br /> FOR DEPARTMENT USE ONLY l7 <br /> APPLICATION ACCEPTEDIr <br /> BY5 *v-------------------------------------------------------------------- ------ DATE <br /> BUILDINGPERMIT ISSUEP---------- - ' ------------------------------------------------------------------------DATE -- ---------------------------------------- <br /> ADDITIONALCOMMENTS--- .------ -- ----- ------------------------------ ---------------=---------------------------------------- ------- <br /> ----------------------------------- ----------------------------------------------------------------------------- -------------------------------------------------------- --------------- <br /> -------------- ---- ------------------------------------ -----------------------------------------------------------------•------------------------------------------- ---------------------------------- <br /> -------------------------------------------- <br /> Final Inspection by-- ------------- <br /> ------------ ----------------------------Date ------- ----------------------------------- <br /> SAN <br /> ----------- ---------------------SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M. I <br />