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i <br /> FOR OFFICE USE: <br /> APPLICATION FOR SANITAT*N PERMIT <br /> (Complete in Triplicate) Permit No. -?E----------------- <br /> This Permit Expires 1 Year From Date Issued Date Issued --- _--_`---.-- I <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 /> _____________________ Y <br /> JOB ADDRESS/LOC N /� �-------<L- -- -c-- - ---CENSUS TRACT --------------•----------- <br /> Owner's Name .--� -- ------ = `�-- - --- -- ------- --------Phone ----- <br /> r , <br /> Address ------------------------------------------•-----------•-- <br /> Z - ��.. . city <br /> t , . <br /> Contractor's Name --- _c c E'er = `„ `X License`# - - `Phone ---------------------•-------- a <br /> Installation will serve: Residencef Apartment House❑ Commercial:[)Trailer Court ;❑ <br /> r Motel ❑ Other ------------------- <br /> i <br /> Number of living units:----i•_------ Number of bedrooms -----Garbage Grinder -------------- Lot Size ---_ ------- 1 <br /> Water Supply: Public System and name ---------------------------------------------------------------------------------------------------------------Private'e <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑' Clay (y Peat❑ Sandy Loam ❑ Clay Loam:❑ <br /> Hardpan ❑ Adobe.E] Fill Material ----- ------ If yes,type ____________________________ t <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 /> Q4 . <br /> PACKAGE TREATMENT [ I SEPTIC TANK'[ ] Size-------------•---------.------------------------ Liquid Depth --------------------,----- v <br /> Capacity -------------------- Type -------------------- Material---------------------- No. Compartments --------•---•--•-----• �` t <br /> Distance to nearest: Well ---------------------------_-_ -:-Foundation ---------------------- Prop. Line ---------- ------ <br /> LEACHING LINE [ ] No. of Lines ------------------------ Length of eoch lin ----------------------------- Total Length ----------------------------- <br /> 'D' <br /> _---.__'D' Box ------- ---- Type Filter Material --------------------Depth Filter Matetial --------.---------___--_-----_------.-----•• { <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 -------------------------------- <br /> Distance <br /> --- .------Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ---------------------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ---_------------------ ) <br /> ------------ <br /> E <br /> Septic Tank (Specify Requirements) --------------------------------------------------------------------------------------------------------------- ------ <br /> Disposal Field (Specify Requirements) ---.- ---� ----,.fix -- = ------- - -�-- -- - --- <br /> -------------------------------------- <br /> -------- -- --------------------------------------------------I------------------------------------------------ ----------------------------- <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, 1 shall not employ any person in such manner <br /> as to become subject to W man's Compensation laws of California." <br /> w <br /> Signed -' - ---- ----- -f--- - --- ------ - Owner <br /> --------- - <br /> BY -------- ------------ -- 4 ---------- Title . � T�,. <br /> (If other an owner) <br /> } FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY:_` •-' <br /> - --------------------------------------------------------- -- ----. DATE - 7�2 <br /> BUILDING PERMIT ISSUED - ----------- ----- -- ------------------------------------------------------------ --- ---------DATE ------------------------------------------- <br /> ADDITIONALCOMMENTS -------------------- --------------------------------------------•----------------------------------------------------------------=--------------------------- <br /> -------- ----- ----------------- ------------------------------------------ ------------------------------------------------------------------------------------------------ <br /> -------------------------------- ------- --- ------------ --------------------------------------------------------------------------------------------------------------------------------------------- <br /> ----------------------- ----- ------ --- - --------------------------------------------------------------------------------------- <br /> Final InsNectio Date <br /> ---- ----------- ------------------ <br /> SAN <br /> JOAQUIN LOCAL HEALTH DISTRICT 101 <br /> E. H. 9 1-'68 Rev. 5M <br />