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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> ------------- ---- ---------------_-----._ Permit No,. <br /> ---------- <br /> {Complete in Triplicate} <br /> This Permit Expires 1 Year From Date Issued Date Issued <br /> ------------ _ ___ <br /> -------------- - ----------_---------- <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. 5.49 and existing Rules and Regulations: <br /> - r ' 1 --- --------------------CENSUS TRACT ----------- ------------- <br /> JOB ADDRESS/LOCATION -�------- ---------=---�-// - ----------�`�,--�-"�-�-„�,� <br /> Owner's Name.- t`'`l V 1' _._.-._. Phone <br /> - 1--� w <br /> �- _. _ _:- <br /> Address , .9 % --------- City ' <br /> Contractor's Name -------- - ----- 1 � .License # - -- ,d _ Phone <br /> Installation will serve Residence Apartment House❑ Commercial []Trailer Court ',❑ <br /> Motel ❑Other -------------------------------------------- <br /> Number of living units ____ Number of bedrooms __�?----Garbage Grinder .--------- Lot Size __ ----____ <br /> .j <br /> Water Supply: Public System and name -------------------------------------------------------------------------- -----------------------------------Private <br /> Character of soil to a depth of 3 feet: Sandf] Silt El Clay ❑ Peat E] Sandy Loam lay Loam ❑ <br /> } <br /> h j 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.) W <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT f ] SEPTIC TANK f ] Size_ ----------------------—---------'----------- Liquid Depth -----_--------------.---•- <br /> Capacity -------------------- Type'-------------------- Material---------------------- No. Compartments ------------------- <br /> i <br />` Distance to nearest: Well ------------------------------------Foundation ---------------------: Prop. Line .--------------------- <br /> LEACHING LINE [ ] No. of Lines -----------------------n Length rof 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 ❑ No 0 <br /> Water Table Depth ------------------------------------------------Rock.Size -------------------------------- <br /> Distance to nearest: Well _______________________________-_--__..Foundation -------------------- Prop. Line ____._-___---.____-___ <br /> I REPAIR/ADDITION(Prev. Sanitation Permit# -------- ----------------------------------- Date ---------------------------------- <br /> SepticTank (Specify Requirements) ------------------- ------------ - ----------- ,=------------------------------------------------ ---------------- ---------- <br /> Disposal Field (Specify Requirements} - - _�•f� ---- -------------- ---------------- <br /> I <br /> ----------------------------------------------------------------- <br /> ------------------------------------------------------------------------------------------------------------=---------------------------------------------------------------------------------------------- <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that 1 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 beco subject to Workman's Compensation laws of California." <br /> Signed -------- Owner <br /> ----- ------------------1--J- c�-----------�----- - ------------ Title ----------------- <br /> (if other than owned <br /> It FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BYDATE -> .2-p <br /> BUILDINGPERMIT ISSUED ------------------------------------------------------------------------------------------------ ---------DATE ------------------------------------------- <br /> ADDITIONALCOMMENTS ---------------------------------------------------------------------------------- -------------------- --------------------------------------- ------------ <br /> --------------------------------------------------------- • <br /> ----------------------------------------------------------------------------------------------------- ------------------------------------------ <br /> ------------------------------------ - ----- ------------------------ ------------------------------------------- <br /> r Final Inspection by: -------------------------- <br /> -----------------------------Date s b--- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F <br /> E. H. 9- 1-'68 Rev. 5M <br />