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FOR OFFICE USE: ., <br /> APPLICATION FOR SANITATION PERMIT <br /> <,r _ <br /> ----------------- ---- ------------------------------ Permit No: __,7/- -- <br /> - <br /> --------=----------------------------------------------- <br /> (Complete in Triplicate) <br /> Date Issued <br /> --------------------------------------------------------- This Permit Expires 1 Year From Date Issued r <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 complia a with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION .--.---` -----a ---------------Y---'---xCENSUS-------..CE TRACT <br /> r ` <br /> Owner's Name ------- --------------------- �Cj /f�� �$ GJ )---------------------------------Phone867---.20? V------- <br /> Address,. ..5;//ee-L------ -- ----------------------------------- i ------------- --- ----------------- <br /> Contractor's Name ------------------------------------License *91 -4Y!?APhone d : <br /> Installation will serve: Residence Apartment House❑ Commercial ❑Trailer Court C1 / <br /> Motel [J Other ------- ------------------------------------ <br /> Number of living units:----I------- Number of bedrooms --_-.Garbage Grinder ------------- Lot Size --- <br /> Water Supply: Public System and name ----------------------•-- ------- ----------------------------------------------------------------------------Private lR <br /> f <br /> Character of soil to a depth-o3 feet: Sand�'Zk-i Sil#rflD�Clay,[] Peat..❑_ Sandy_Loa ❑. a <br /> �C.lay.Lom ❑ <br /> Hardpan ❑ Adobe.0 Fill Material ----- ------ If yes,type _--_-------"-_-_______--_-- <br /> a � <br /> (Plot plan, showing size of lot, location 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,] <br /> PACKAGE TREATMENT : Size X-/ Liquid Depth .__! ---- ' <br /> ------- <br /> -SEPTIC TANK![ I <br /> rr -- - <br /> No:: ents Capacity Type Material . V ' <br /> 1 Distance to nearest: Weil --------------------Foundation ...L --r...__._. Prop. Line --- --------- <br /> s <br /> LEACHING LINE { ] No. of Lines ___._ __ I"----- Length of each line------ <br /> --------------------- Total Length --✓8----------I....... <br /> s - 'D' Box _:_ ------ Type Filter Material/�r� .____Depth Filter Materiaf __.. ----------------------------- -- <br /> ] Distance to nearest: Well, -------- Foundation ------l.-0...-_.. _. Property Line, :0.................... <br /> • 'SEEPAGE PIT [ ] Depth ________________ ___ Diameter ---------------- Number .._._.___------ ----------- Rock Filled Yes ❑ No ❑ <br /> Water Table Depth ----- -= --------•-------Rock Size ------- ------- --------------- <br /> I Distance to nearest: Well -----------`-------------------------- --Foundation -------------------- Prop. Line ----------------.----. y <br /> i REPAIR/ADDITION(Prev. Sanitation Permit # ------------------------- Date ------------------------- -_ -) <br /> Septic Tank (Specify Requirements)------- ----------- --------------•-----------------------...__,,.--------------------------- � <br /> DisposalField {Specify Requirements) -------------------------------------------------------------------------------------------------------------------------•----------- <br /> ------ ------- ----------- - --------- ---------- <br /> - - - �-�-,,.mss..-��::� . .,� .•.� _ _.. - .---.. - - �.; „_ - - - - _ .. <br /> - 'r <br /> (Draw existing and required addition on reverse side) <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin i <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 /> igned ---------- - ---------------- - Owner <br /> - -------- ---- _ <br /> BY --- - - - --------------------------------------------- Title ------------------------------------ ----------------------- ---------- <br /> (If other than owner) ` <br /> FOR DEPARTMENT USE ONLY ! <br /> APPLICATION ACCEPTED BY-:- r --------------------------------- DATE ---- `�S ! �/ <br /> BUILDINGPERMIT ISSUED - --------------------------------------------------------------------------- -------------------------DATE ------------- ----------------------- <br /> ADDITIONALCOMMENTS ------------------------------------------------------------------------------------------- ------------------------------------------------------ ---------- <br /> ----------------------------------------I-- <br /> -------------------------------------------------'-- ------------------------------------------------------------------------------------------------------------ ------------------------------------------------ <br /> ----------------------- ------/I --------------------------- -------------------- =-------------- -------------------------------------------------- <br /> ------------- --------------------- - ----- - ---------- - - <br /> -- -- ---------------- -- <br /> - <br /> ---------------- <br /> Final Inspection by. ----- ------- '`--- --------- ----------- ----------------Date --- <br /> --Z&7 ~- f <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> c, _ <br /> E. H. 9 1-'68 Rev. 5M <br />