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I-OR OFFICE USE: APPLICATION FOR SANITATION PERMIT y <br /> S Y <br /> Permit No. <br /> a (Complete in Triplicate) <br /> ------------------------------------------------ -- Date Issued <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 compli ce with County Ordinance o. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION -eat----- -- - -� � CENSUS TRACT --------------------------- <br /> Owner's Name 15` �' '. y ° = ---------- - -------------------Phone <br /> Address --- Cit �'fr?�f� nl '� A <br /> Contractor's Name .` 1 _e �S *--- SON --=--------License# �tJf�-�r~I I Phone��?Sr6 d7_.... <br /> Installation will serve: Residence $Apartment House❑ Commercial :❑Trailer Court 0 <br /> + Motel ❑ Other ----------------------------- ------------- <br /> Number of living units:...CA) _- Number of bedrooms C"'Q---Garbage Grinder ._y(ZS_ 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,tYPp---------- ------------'----- <br /> f <br /> {Plot plan, showing size .of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> I' NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK <br /> Y ----------- [--_] Size------------------------------------------ <br /> Liquid Depth --------------------------- C, <br /> Capacity Type -------------------- Material---------- ------ 1,4o. Compartments -------------•-------- <br /> p Yp <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 _.__------____--______--_-____--______..__ <br />` Distance to nearest: Well ----------------------- Foundation ----- --------------- -- Property Line ------------------------ <br /> SEEPAGE PIT Depth ------ Diameter ---------------- Number _'�-------------------------- Rock Filled Yes Q No 0 <br /> _,,,_Water. Table. Depth--------------------------------------------------Rock Size ------ ------------------------- <br /> Distance to nearest: Well .----- --------------------------------Foundation -------------------- Prop. Line --------- --------_-- <br /> Date -------------- ------------------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ---------- <br /> Septic } <br /> Tank (Specify Requirements) --------- = '-----IS------ ---------- <br /> Fay- <br /> Disposal Field JS ify Require nts) _--_0-Q_-- 1 <br /> ------- --- J --- m <br /> ------------ ----- --- --------------------------- <br /> - <br /> ----- -- - --- <br /> - - ----------- ------- <br /> - - <br /> --------------- -- - <br /> �. {Draw existing an a uired addition n'reverse side) <br /> I hereby certify that I have prepared this application and that the work will be don 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: r <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 Com ensati.on laws of California.'.' <br /> Signed ---- -- ------ -----.------- -- Owne <br /> BY i, � --- -- -- -'------- Tifle ' � <br /> (If other than owne <br /> ~'4 <br /> FOR DEPARTMENT USE ONLY <br /> 49 <br /> APPLICATION ACCEPTED SY -------------------------------------- -----------------------. DATE - =� r <br /> BUILDING .PERMIT ISSUED --------------- -------------I-------------------------------------------------------------------DATE ------------------------------------------- <br /> ADDITIONAL COMMENTS ------------- - =- /--------------- --------------- ----------- --------------- <br /> -----------------------------------------------)___:-- ------------------------------------------------------ <br /> --------------------------------------------------------- ------------- --------------------------------------------------------------------------------------------------------------------------------- <br /> Final Inspection by. -- ---------------------------------------------------------Date -.��----------ta------ - ------ -- --- <br /> ------------------------ ------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'b8 Rev. 5M. <br />