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FOR OFFICE USE. <br /> APPLICATION FOR SANITATION PERMIT <br /> - Permit No. _��/ 5� <br /> (Complete in Triplicate) <br /> " ----------- Date issued 0 <br /> 7--:6117- <br /> ___________-------------------------------- � This Permit Expires 1 Year From Date Issued <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 . /--4-- 7_1----------- ------------------------------- <br /> CENSUS TRACT <br /> 2-149 <br /> Owner's Name -. -` ___. _ _ _._.,.____-Phone --1-�1�--____- _ <br /> ! - - ------------------- <br /> Address1A10----- ----------------------------- ------------ City -------- - <br /> Contractor's Name - -1 :-----.{icense # 17J�---- Phone _ _` �. Z"� <br /> Installation will serve: Residence gApartment House-E-] Commercial:❑Trailer•Court ;❑ <br /> Motel ❑Other ------------------------------------------ <br /> / r <br /> Number of livingunits:____!____- Number of bedrooms __ ��- ��� <br /> -----/--Garbage Grinder __.___._____ Lot Size _____________�..__ ____ <br /> _/fes�-f --- <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, locotion'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,) °Q <br /> PACKAGE TREATMENT [ ] SEPTIC TANK[ ] Size-------------------•---•-----------------------__.. Liquid Depth -------------------------- <br /> Capacity ----------------- Type Material - ---------------- No.I.Compartments ---------------------- <br /> Distance to nearest: Well-__-___-___ ____________Foundation ---------------------- Prop. Line --,_-___-.-_____-_____ <br /> LEACHING LINE { ] No, oflines ________________�.__ .Length of each line- --------------- ------ Total Length ,_________-_____--____._-_- <br /> 'D' Box __ __--- Type Filter Material ___________________Depth' Filter Material -------------------------------------------- <br /> '%,,,,,.L�` <br /> Distance to nearest: Well ______________________ Foundation ------------------------ Property Line. _________________--____ <br /> SEEPAGE PITDe th # <br /> [ 1 p -'---------------- Diameter ________________ Number - _ ____________ Rock Filled Yes ❑ No <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) ----------------------------------------------------------------------------------•-------------------------...... --------------- ----------- <br /> t 4 It <br /> DisposalField (Specify Requirements) -----------------=----------------------------------+--------------------------------------------------------------------------------- <br /> --------- -- ------ ----- -------------------- <br /> "f= - ---------- - ---- ------- <br /> X10 G� � -- - --------- �-- <br /> IIhL�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 /> "1 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 becosubje t to Wor n's pensation la of California." <br /> Signed - ------- ------- --- ---- Owner <br /> BY -------------------- ----------- --- ----------- -- Title ------------------------------------------- --- ---------- ------------- <br /> (If other than owner <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ------------ _ `------------------ ------------------------------------- ---------------- DATE - -0 6y--------=-------------- <br /> BUILDING PERMIT ISSUED - ----------i - ----------------------------- --------------DATE ------------------------------ ------ <br /> ADDITIONAL COMMENTS ----------- `----------- - <br /> -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -- ----- --------- <br /> --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- - - ------------ <br /> ----------------------------------=-------------------------- <br /> Final Inspection by; ------------------------------ -` ---- -- v --------------------------------------------------------Date 77f d ----------- --- ----------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'6$ Rev. 5M V <br />