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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ' [Complete in Triplicate) Permit No: <br /> -- -----_------------------------------------------------ �.�.�......._... �� _- Date Issued <br /> --------------------------------------------------------- This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to the San Joaquin Local Health Districtl for a permit to/ nstruct and install the work herein <br /> described. This application is made in compliance with County Ordinance No. 549'an'd-existing Rules and Regulations_ <br /> D <br /> JOB ADDRESS/LOCATION __-_- -- ------ -- ------__-. -------------- ---- ^F---CENSUS TRA& --- -------------- <br /> Owner's Name " r�'r .r------=---------- - one ----------------------------- <br /> Address - - City ' y ----- <br /> Contractor's Name _ - ---------------- -----License# Phone, _ ���� <br /> Installation will serve: Residence)Sllpartment House f❑ Commercial❑Trailer Court J3 <br /> I Motel ❑Other--------------------------------------- <br /> Number <br /> ------------------------_---------_-Number of living units:___/- Number of bedrooms � Garbage Grinder ------------ Lot Size ` _____________ <br /> Water <br /> 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 ❑ Adob�W Fill Material ------------ If yes,type-___-----__-_--_-__-_--- <br /> (Pl'ot plan, showinglsize 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 [ ] , SEPTIC TANK ] `,"' - Size------------------------------------------------ Liquid Depth ----------------w_----------.- <br /> capacity ----------------- Type --------------- Material---------------------- No. Compartments ---------------------- CA <br /> Distance to nearest: Well ------------------------------------Foundation --- ,___--__ -- Prop. Line,---------------------- <br /> LEACHING LINE C`) No. of Lines ------------------------ Length of each line------------------ Total Length ----µ_'Vi--------------- 6 <br /> ' x <br /> 'D' Box ------------ Type Filter Material --------------------Depth Filter Material ---------------------------------------- <br /> Distance <br /> ---------------------------------------Distance to nearest: Well ________________________ Foundation ------------------------ Property Line_ -------.._______--._..-_ <br /> SI EPAGE PIT [ ) Depth -------------------- Diameter --------.- ----- Number --------------------------- Rock Filled Yes [] .,No ] <br /> WaterTable Depth ---------------------------------------=--------Rock Size ---------------------------------_k <br /> Distance to nearest: Well --- -----------------------------------Foundation} -------------- --_. Prop. Line ----------------- a <br /> REPAIR/ADDITION(Prev. Sanitation Perm it# ---_-P- d - -------------------- Date ---'` /-/fe! �-i�---------) <br /> Septic Tank (Specify Requirements) --------------------- -------------------- -------------------------- <br /> �" <br /> Disposal Field (Specify Re uirements) ..._ -------------/�J__._-�l_�________ <br /> --- V ....---� ' ------•--•----------------- ---------------- ---------------------------------- <br /> __: 1 <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 Diaastrict. Homme owner or lGirt <br /> sed agents signature certifies the following: <br /> "I certify that in the performance pf the work for which this permit is issued, I shall not employ any person in such manner <br /> as to become subject to Wo m s Compensa laws of California'." <br /> Signed ____ .1494-1_ .- - Owner <br /> _... <br /> BY _�._4-` ----------- Witte ----------y---------- <br /> ------------------------------------------------- <br /> (If other than owner) ". <br /> A;��;"RD TMENT USE ONLY <br /> APPLICATION ACCEPTED BY--- -- ------- -- - - - --------------------------------------------- DATE -------------- <br /> BUILDING PERMIT ISSUED .. - - --- ------------------------------D TE <br /> ----- -- --------------------- -- ------ <br /> ADDITIONAL COMMENTS - ----- - --- ----- ------- <br /> ... --- -- --- -- -- -------------------------- ----R _-_ ____ -----..-----------------------..._-- -_-_-_ <br /> . <br /> .....-• ---------------------------- ---- -- ----- ---- ----- <br /> ___.•................................... ....... .. . ... -�. ..........___.___-____. --- ---------- --- --- -__ <br /> --------•----•-----•-----• --- ----------------- -Date ------- <br /> -.-- - �. <br /> Final Inspection by: --------------- ----- <br /> --- - <br /> J IN LOCAL HEALTH DISTRICTt <br /> E. H. 9 1-'68 Rev. 5 <br />