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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ------------------------------------- - ----- <br /> (Complete in Triplicate) <br /> Permit No: _77 _'_�r__ <br /> --------------------------------------------------------- This Permit Expires 1 Year From Date Issued <br /> 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 . Q? --- - -------- 1 '------------------- - ------CENSUS TRACT -------------------------- <br /> Owner's Name ------ ----- --- -------- -- &--- ---------------- -------Phone ------ --- � <br /> �J /__ -9---- <br /> Address ----- ---------- �2�GJ�- -, L-�/--- r <br /> Contractor's Name ---------- ------ ~----- ---- J0'~-------------:--------License #/490_1`v11--- Phone 5-1XV-`_/_W1_f--. <br /> Installation will serve: ResidenceFRf Apartment House-E] Commercial ❑Trailer Court ;❑, <br /> Motel ❑ Other --- -------------------------------•-------- <br /> Number of living units:_-/------- Number of bedrooms _______Garbage Grinder __ _ __ Lo Size ------ NV��, 57......... <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 /> (Plat plan, showing size of lot, location of system in relation to wells, b1clings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: {No septic tank or seepage pit permitted if public sewers available within 200 feet,) // <br /> PACKAGE TREATMENT [ ] SEPTIC TANK' Si __ __ ______________________ Liquid Depth ---� -------------- <br /> Capacity l _._ Type Material No.No. Compartments _--__-Z......... <br /> Distance to ne rest: Well ___.___________________'_:___--Foundation __LOQ_'________ Prop. Line __�---r <br /> LEACHING LINE [ ] No. of Lines ------------------------ Length of each li,ne'______`_•-_1-------------- 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 ❑ <br /> Water Table Depth ------------------------------------------------Rock Size ------ ------------------•------ <br /> Distance to nearest: Well _______________________________________Foundation -------------------- Prop. Line ...................... <br /> a � <br /> REPAIR/ADDITION(Prev. Sanitation Permit# __________ __________________ Date ______ ___ _______________I <br /> Septic Tank (Specify Requirements) ��4 � --- - ------ ----------- --------- <br /> Disposal Field (Specify Requirements) __ ________ _ _ _____ t- _________ ------------ <br /> ---- -------------------------------------------------- ------------------------------------------------------------------------------- <br /> _____________--_______________________________________.___________.--__------_------------_-___-________________________._________-___________.___ ---------------- _______________________________.__________________ <br /> ___________________________________________________________________________________________________________________________________________________ ______________________________________________________ <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, I shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed ----------- -------------------- <br /> {I ---- <br /> - -------r---------- Own <br /> er <br /> --- ----------- --- <br /> -------------------------------------------- <br /> BY - -------- <br /> Title <br /> other n owner) <br /> i DEPARTMENT USE ONLY r <br /> APPLICATION ACCEPTED BY -------------------------------------------------------------- DATE ---- =�r= --- <br /> PERMIT ISSUED ------ ---- ----------------------------------------------------- <br /> ADDITIONALCOMMENTS ------ ---- ----- -- ------------------------------------- ---------------------------------------------------------------------------------- <br /> -------------------- -------------------- -- ------ - ---- - - --------------- ------------------------------------------------------------------------------------------------------------------- <br /> --------------------------------------- - - - --- - ------ - - ------------------------------------------------------------------------------------------------------------------------------------- <br /> Final Inspection b Date <br /> S N JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Re . 5M <br />