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i <br /> FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> -------------------------------------------- <br /> (Complete in Triplicate) Permit <br /> - ----------------------------------------- -- <br /> a--�., s r`Date Issued <br /> Ttiii- ermit Expires 1-Year Frani Date Issued <br /> P <br /> s - f <br /> f Application is hereby made to the-Sari 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 nd existing Rules and Regulations. <br /> JOB ADDRESS/LOCATION -- . _ 1- .-_-_CENSUS TRACT -- 1- "3 <br /> - - ----- <br /> Owner's Name <br /> ----------------------------- -------:---Phone ------------------------------ <br /> Address .--_ `" <br />� �� --��-°'------------ - ' - --• -----------�: _r_::<•-�--------------. City f ------ ----------------- <br /> Contractor's Name ____ � - g.,.,�- " - -" _-_-____---- .License # - <br /> ' "' a �i . . j Phone <br /> Installation will serve: ResiAnce)gApartment.Howsw[g.Commeorcial:❑Trailer Court '0 <br /> Motel ❑ Other -------------------------------------------- <br /> Number of living units:---/----- Number of bedrooms -X-_--Garbage Grinder y Lot Size -- f _-___-___-__ <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 /> (Plot <br /> ------------------- --"---(Plot plan, showing size of lot, location of system in relation to wells, Buildings, etc. must be placed on reverse side.) tv <br /> NEW INSTALLATION: (No septictankor seepage pit permitted public.-sewerif- is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC 7 NK Size" "X_9--X -----.-.-_------_ Liquid Depth,�_ ----------------- <br /> --------- <br /> ---------------- �• <br /> ;. <br /> Capacity -_____.__ Type�j 1> Material_- .--- No.*Compartments ------------------ <br /> Distance <br /> -- -_Distance to nearest: Well _ ---- . --------------------Fou.ndation Prop. <br /> o Li <br /> LEACHING LINE No. of Lines .--------------- Length of epch line.__t�-�--- - Tofal Length ------------- <br /> 'D, <br /> -- --'D, Material <br /> d ` <br /> Box -e-r- . Type Filter Materiae/ . !Depth Filter <br /> r Material���-------------------------------- <br /> ----------- <br /> ---------- <br /> - <br /> ------_ _-FoundationDistan o-nearest: Well XoProperty Line - --------_-_..4_ <br /> s <br /> SEEPAGE PIT t '. Depth R%_F7---_-__ Diameter _- Number _ ------------------- Rock Filled Yes No .iQ <br /> : " <br /> Water Tablb De th / �-------------------------- --------Rock Size ----- - <br /> ;11 Distance to nearest: Well -------------------_Foundation :�F�-------- Prop. Line _-_-___-_- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ____---_.----.___--_-_--__-_-_-_--) r <br /> Septic Tank (Specify Requirements) ---------------------------------------------------------------------------- = <br /> Disposal Field (Specify Requirements) ------------------------- <br /> ---------------------------------- <br /> ------------------- ----------------------------------- - ----------------------------------- ------ -- ------------ <br /> ------------- ---- ------------------------------------ ------------------- -------------------------------- <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 become subject to Workman's Compensation laws of California." <br /> Signed - - — Owner <br /> ;F <br /> "_`__ <br /> --- -----------------TTitle <br /> (If oth an owner <br /> - FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY --- /- ;7 <br /> -- - --------------- "�--------------------------------------=---- C' ..-:" <br /> ----------- =DATE *�: /� _ <br /> BUILDINGPERMIT ISSUED -------------II-------------'------ ----- ------------------------------------------------------- -------DATE ------------------------------------------- <br /> ADDITIONAL COMMENTS ------------- --------------------------------------- - <br /> ------------- <br /> '' <br /> ` --- --------------------- <br /> -------------------" <br /> a <br /> --. .--- <br /> Final InspectionbY= � - te � ! T . '---- -------- - ----------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT ,. <br /> E. H. 9 1-'68 Rev. 5M � <br />