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i <br /> FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> Permit No. <br /> --------- ----------- ---------- ----------------------- (Complete in Triplicate) <br /> ---------------------------------- r <br /> ---- -- ------ �c�te issued <br /> � -_�__�-�---- <br /> This Permit Expires 1 Year From Date Issued <br /> - <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein j <br /> described. This application is made in compliance with County Ordinance'No. 549 and existing Rules and Regulations: <br /> // _ ----------------- ---CENSUS TRACT --------------•----- <br /> JOB ADDRESS/LOCATION -2-1­ - ----------- - <br /> ---------Phone 9- _ <br /> Owner's Name ---494�_ �.[------- ------ ---- ----------------------------------- c <br /> /04 ---,- --------- # . city __ fit <br /> --------------- <br /> Address <br /> --------------- <br /> � � �y -.License # _ .j -3_Z__ Phone <br /> Contractor's Name <br /> Installation will serve: Residence,'5�Apartment House,❑ Commercial :❑Trailer Court l❑ <br /> Motel❑Other ----------------------•--------------------- <br /> Number of living units:.----------- Number of bedrooms�-_�_-=_.Garbage Grinder -----:______ Lot Size ____________________________________________ <br /> ' <br /> Water Supply: Public System and name -------------------------------------------------------------- ------------- <br /> --------------- - ----- ------------------------------------=---:-------- <br /> ---------------------------- ------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 plan, showing size of lot, location of system in •relation to wells, buildings, etc.4'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 /> ° r ri <br /> PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] Size_�_a`------- _ (-_� Liquid De --- ----------------.--- - <br /> , ,r ateridl__ No. Compartments ----�-,F- ------ �'I <br /> Capacity Jia------- Type r <br /> r ----- Prop. Line <br /> Distance to nearest: Well -- -------------------------- <br /> No. <br /> ______��-__-- f <br />. t - <br /> No. of Lines --_____ Length of each line,--------------------------- Total Length <br /> LEACHING LINT: [ J1. ff <br /> • " ----Depth Filter Material _ �-----------•---------------- <br /> 'D' Box __/-------- Type Filter Material _�--_-----__ <br /> r <br /> f --------- Foundation . ------` Property Line. -- ---- ----------- -- <br /> Distance to nearest: Well - ____ -- <br /> SEEPAGE PIT [ ] p -_------ Diameter ---------------- Number ------------------ Rock Filled Yes ❑ No <br /> Depth ------ -�-- <br /> Water Table Depth ----------------------------Rock Size <br /> Distance to nearest: Well ----------------------- -------------------- Prop. Line __.. <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------- ----------------- Date ----------------------------------) <br /> Septic Tank (Specify Requirements) --------------------------- - ----- ------------------------------------------------------------------------•-----"---- <br /> Disposal Field (Specify Requirements) ______________ "-- ------ --------- "---"--"--"-" "-------"" - <br /> - ------ -- <br /> ------------------------------------ --------------------------l------------------------------------------------------------ <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: person in such manner <br /> "I certify that in the performance of the work for which this permit is issued, I shall not employ any <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed ---- ---------------------------------------------------- Owner <br /> itle _ h `J <br /> ` --------------- <br /> (If other than owner) <br /> r <br /> FOR DEPARTMENT USE ONLY <br /> DATE _ "_------------ -------------- <br /> APPLICATION ACCEPTED BY - - ------ -- - ------- DATE ----- ------------------------------------- <br /> BUILDINGPERMIT ISSUED ------------------------------------------------------------------------------------------ <br /> ADDITIONALCOMMENTS ------------------------------------------------------------------_------------------------------------------"-------------------- ----------•---------------- <br /> ------------------------------------ <br /> ------------------------------------- <br /> ------------------------------------------- <br /> _ ------- --- ---- ---- ------ ---------------- ------------------------------ --- ----- -- <br /> - <br /> D <br /> ------------------------------------------ <br /> ---- <br /> e <br /> Final Inspection b c - <br /> ---- -- <br /> C -� ate <br /> ---------------------- <br /> SA JOAQUIN LOCAL HEALTH DISTRICT <br /> i <br /> 1 E. H. 9 1-'68 Rev. 5M <br />