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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT f <br /> � � --------------- Permit No: <br /> - <br /> (Complete in Triplicate) <br /> Date Issued <br /> This Permit Expires 'I Year From Date 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 complia�' County Ordinance No49an exi &RKles andRegulations: <br /> 7� �- � .f` �_ rmTRACT ------- -`--- --_--- <br /> JOB ADDRESS/LOCATION -_- <br /> �`1 i/ y_5_21.. ------------------------------------- ----- - - ------- ---------Phone <br /> Owner's Name - - ------=�--..�,.�'.��-�-�-----�---1-�� - = - - <br /> Address --------- ------------------------------------------------- City _Avcoo :--------------`------------------ <br /> Contractor's Name __-- - ---- - License # � -- - Phone s _-- ` _-_ <br /> 1../Z --------------- -------- <br /> I <br /> Installation will serve: Residence f�Apartment House❑ Commercial ❑Trailer Court !❑ <br /> Motel ❑Other ---- --------------------------------------- <br /> Number of living units:----- Number of bedrooms ________Garbage Grinder _--____..- Lot Size _ 'd `- --------------------- <br /> Water <br /> - --------•• <br /> Water Supply: Public System and name ---------------------- ---------------------------------------------------------------------------------------Private E9 <br /> Character of soil to a depth of 3 feet: Sand'LN� 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. must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) v <br /> PACKAGE TREATMENT [ I SEPTIC TANK f ] ____________ Liquid Depth _ ': .------------- 1 <br /> Capacity-/6Z_9-z----- Type 't-�f_�` _ =Material__l ¢ �- No. Compartments -------------•----- ` <br /> � <br /> v <br /> Distance to nearest: Well ____ _ `f---------------------Foundation __J_6_=---------- Prop. Line .--S_f...:--------- <br /> I <br /> LEACHING LINE [ ] No. of Lines ____-r _____________ Length of each line-------7-_---_.___-----__ Total Length ---------------- <br /> 'D' Box ------------ Type Filter Material �� ---Depth Filter Material ___ ----------------------------------- <br /> r Distance to nearest: Well __ ------------ Foundation _fes -- ------------- Property Line -__--________________ <br /> SEEPAGE PIT [ ] Depth --J---------------- Diameter-' ________________ Number ____------------------------ Rock Filled Yes ❑ No 0 <br /> WaterTable Depth ------------------------------------------------Rock Size -------------------------------- <br /> - <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ------------.......... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) <br /> i. <br /> Septic Tank (Specify Requirements) ----------------- ------- --------- ------------------------ ------------------------ ----------------..__,..--------------------------• <br /> t <br /> Disposal Field (Specify Requirements) ------------- ---------------------- ------------------------ <br /> 1 <br /> ------------------------------ <br /> --------------------------- -------------------------------- -------------------------------------- ------------------------------- <br /> f <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 Compensation laws of California." <br /> Signed ------- ------=------ Owner <br /> 3 <br /> � BY -------------- - ----�- ------ - --- -- �: ------- -------------- Title Title ----------- ------------------ ---------------------------------- <br /> ( fother than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ---- 4� ---------------------------------------- -------------------- -------------- DATE -----e5 -------- <br /> BUILDINGPERMIT ISSUED -------------------- ------------------------------------------------------------------------------------DATE _.----------------------------------------- <br /> ADDITI.ONAL COMMENTS --------- } ---------------- --------------------------------- --------------------------------------------------- ------------------------------------------ <br /> ----------------------------------------------------- ---------------------------------------------------------------------- ---------------------------------------------------------- ---------------- <br /> ---------------------------------------------------- <br /> ----------------------------------------- --- <br /> -------------------- ---------------------- + <br /> --- -- ------- <br /> ------------------------------------ =--- ----- ----------- ----- --- ---- - - -- - ---- - <br /> Final Inspection by- ---.Dated <br /> } SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />