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FOR OFFICE USE: ���� <br /> "APPLICATION FOR SANITATION PERMIT <br /> i (Complete in Triplicate) /� Permit No. <br /> ------------------------ This Permit Expires 1 Year From Date Issued a 7�) ©ate 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 <br /> - CENSUS TRACT . <br /> Owner's Name ------------------ `-------- -•----- --------- -------Phone 7�P _.?Q --- <br /> ------ <br /> Address --------------------------- '� -�/ ._.City - - r �------------------------------------------- <br /> ----------- <br /> Contractor's Name 'i- -r�t/� License ----- Phone 7rp <br /> f: <br /> Installation will serve: Residence %Apartment;House-❑ Commercial ❑Trailer Court ;❑ <br /> } <br /> Motel ❑-Other----------------------------------------- <br /> Number <br /> -- ----------------------•-Number of living units:____ ___ Number`'of!bedrooms ---Garbage Grinder _____-_7 Lot Size (oQ�VY -------------- <br /> 1 � <br /> -----Private <br /> Water Supply. Public System and name ------------------------------------------ --------------••1-------••------- ❑ <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ -Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan [:] ll[Adobe FiMaterial ----------- If yes, type ____________________________ <br /> I <br /> 1Pl'ot plan, showing size of 16t, location of system in relation to wells, buildings, etc. must be placed on reverse side.) SNI <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) �1 <br /> PACKAGE TREATMENT [ ] SEPTIC,,TANK�[ ] ' -„-_-Size------------------------------------------------ Liquid Depth -------------------------. <br /> Capacity `k 1 ----------- Type ,_'n---------------- Material------------------ #- No. Compartments -----------_-------- <br /> Distance to nearest: Well ________________---___ __________Foundation ___ __________ Prop. Line _______________----- _ <br /> LEACHING LINE [ ] No. of Lines '________________________ Length of'each-;Iirie�_----€ - Total Length <br /> 'D' Box ------------ Type Filter Material ------------------- Depth Falter Material -------------------------------------------. <br /> Distance to nearest: Well --- ----- =R_-_.____-- 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__i--------------------------------Foundativr� ________________ Prop. Line --------- ------------ <br /> REPAIR/ADDITION(Prev. Sanitation Pelrmit# --------------_----------------------------- Date ------------- ._____.-____-_______j <br /> Septic Tank (Specify Requ' --n-p� <br /> P (Specify irements) t-----_---- ----- ---.. <br /> --- ---------- - - - <br /> Dis osal FieldRequirements} ___ ___ _____ Cn _'- - ,.----- -✓�.--------- --- - I'»_--=.--- <br /> ---------------------- ---- -- }, ---------------- <br /> L (." ---- ---- X-z------ - ''1 <br /> i <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 Compensati.o'laws of.California <br /> Signed "L/---Wtn <br /> - - Owner s <br /> . Title . <br /> (If othowner[ <br /> FORADEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY . - --------------------- --------------------------------------- DATE ---------------- <br /> BUILDINGPERMIT ISSUED - --------------------------------a _,f-----------------------------------------------=--------------DATE ------------------------------------------- <br /> ADDITIONAL COMMENTS ------------------------------------------------------------------- ------------------ ------------------------- ----------------- --------------------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ----------------------------------------- ---------------------------------------------------------------------------- ---------------------------------------------------------------------------•---- <br /> ------------------------------------ - <br /> Final Inspection by: --------- Y _ Date -1 - <br /> SAN JOAQUIN L6CAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M '` C' <br />