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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ------------- --- ---------------------------- ------ Permit No. 7r y�-- <br /> _(Complete in Triplicate) <br /> --------- - -------- <br /> � � <br /> -- -- <br /> ------------------------------------------------------ This Permit Expires 1 Year From Date Issued Date Issued G-`}" <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 ---------------------------CENSUS TRACT ------------- ----------- <br /> © __ <br /> Owner's Name ------------ -- _ <br /> Address . ,0A- -------- City g e v-o -------------------------------------•---•------ <br /> Contractor's Name ---�'Jz _�.__ �� f 4B <br /> --�?_rL-21S1-f---f"------�As # ----- - ---------------- Phone ------------` ----• --• -• - <br /> Installation will serve: Res idenceXApartment House❑ Commercial ❑Trailer Court ',❑ <br /> Motel ❑Other ----------------------------------- -------- <br /> Number of living units ----- Number of bedrooms _0------ Grinder .----------- Lot Size ---- ___------------- - -"-----. <br /> Water Supply: Public System and name ---------------------------------•---------------------------------------------------------- -----------------Private <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam 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 --------------------------- V, <br /> Capacity --------------------- Type -------------------- Material---------- No. Compartments ----------- --•----- .� <br /> Distance to nearest: Well ------------- O <br /> -----------------Foundation -=---------- ------ Prop. Line --------........------ O <br /> LEACHING LINE [ ] No. of Lines ------------------------ Length of each line---------------------------- Total Length ------_--_-_-----_-_---.__-. <br /> 'D' Box ------------ Type Filter Material --------------------Depth Filter Material -------------------------------------------- <br /> Distance <br /> ---- -_----------_----_--..._-_---__-.-.-_.Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line ---_---_-_--.-_-_---_ <br /> SEEPAGE PIT [ J Depth ---------------- --- Diameter ---------------- Number _--- ----------------------- Rock Filled Yes ❑ No If <br /> Water Table Depth ------------------------------------------------Rock Size ---- --------------------------- Ur <br /> Distance to nearest: Well ----------------------------------------Foundation -------------- ---- Prop. Line ...-------------------M <br /> REPAIR/ADDITION(Prev. Sanitation Permit -_------------------- --------------------- Date ----------------------------------) T <br /> ----s ---n[.�- ----- <br /> h <br /> Septic Tank {Specify Requirements) ________.--- <br /> w <br /> Disposal Field (Specify Requirements} c..�� -------- -------------- �'�`�"`'" <br /> t r „ <br /> - ----- -- --e <br /> -------�--- --. - _ __ � <br /> (Draw exi ing 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 sub' o Workman's Compensation laws of California." <br /> Signed ------------------------a -----------------------fir <br /> By ------------------------------- ---------------- Title lC�i/. �n� ------------------------------- <br /> (lf other than owner) (� <br /> P DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ---- '------------- -- -- -------------------------------------------------------------------- DATE _1�'--�"3---- -- -------------•- <br /> BUILDING PERMIT ISSUED --------- ------------------------------- DATE <br /> -------------- <br /> --------------------- ----------------- <br /> COMMENTS --------------------------------------------------------------------------------- --------------------------------------------------------- ----------- ------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ------------------------------------- <br /> -------------- <br /> -------------------------------------------- ----------------------- - ----- <br /> --- ------------------- <br /> ------------------------------------,-�- - - - -------- --- ---------------------------------------- ------------------------------------------- <br /> Inspection by gg - - Date 1. <br /> t� <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H, 9 1-'68 Rev. 5M <br />