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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ------------ -------------------- <br /> (complete in Triplicate) Permit No. �Q_- - <br /> �7 <br /> - ._ <br /> This Permit Expires 1 Year From Date Issued 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 ccoo°mpliance with County Ordinance No 549 and existing Rules and Regulations. <br /> JOB ADDRESS/LOCATION _ �----Y--- . 'U--- `-' CENSUS TRACTOwner's Name --------- - - ------- -- ------- -- -------Phone ------------------------------------ <br /> Addressr City <br /> r <br /> Contractor's Name ------- -- .- __ - u_� License # ���.3y-- Phone ----------------------------- <br /> Installation will serve: Residence [Apartment House❑ Commercial:❑Trailer Court i❑ <br /> Motel ❑ Other --------------------------------------- ---- <br /> Number of living units:____,_____ Number of bedrooms 19______-Garbage Grinder ------------ Lot Size _____ _______________________-___-____-_-- <br /> Water Supply: Public System and name --------------- ------------ ---•------------------------------------- ----------- ---------------------------Private <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt D a Clay ❑ Peat❑ Sandy Loam [iT11"Clay Loam.0 (1� <br /> Hardpan EJ 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.) <br /> NEW INSTALLATION: (No <br /> osp seepage pit permitted <br /> -- - public sewer is available within 200 feet) <br /> PACKAGE TREATMENT SEPTIC TANK€ Sze -- - - -`--------------- <br /> Liquid Depth -------------------------_ { <br /> Capacity ------------------ Type ----=--------------- Material------------------------No. Compartments ---------------- ` <br /> r <br /> Distance to nearest: Well ------------------------------------Foundation -----------------------.Prop. Line ---------------------- <br /> LEACHING <br /> --------- :_-----.LEACHING LINE [ ] No. of Lines --------- -------------- Length of each line----------------------.-------- Total Length ,_________-..----_-________-- x, <br /> 'D' Box ------------ Type Filter-Material --------------------Depth Filter Material 1=------------------------------------------- , <br /> Distance to nearest: Well ________________________ Foundation ------------------------ Property Line, --------- -------------- <br /> r <br /> SEEPAGE PIT [ ] Depth ___________________1. Diameters______-_________ Number --------------------------__ Rock Filled Yes ❑ No <br /> Water Table Depth --------------Rock Size__ --------------___4-' <br /> Distance to nearest: Well ------ --------- ......._--------------Foundation --:-:--=--'--------- Prop. Line -----------_-------- t <br /> -- ' -: ' Date `------ <br /> REPAIRJADDITION(Prev. Sanitation Permit# --------------- ----`- 1 <br /> SepticTank (Specify Requirements) ---------------- --------------------------------- ----------_------------------------------------------------------- •--------------------------- <br /> Disposal Field (Specify Requirements) -- _ c � !._ _ � ---+ -� --14-- ---- ---- ----- <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 /> ------- -------- <br /> Signed ----- --- --------- ------ -------- <br /> _ _ _ Owner <br /> BY ----------- -------------- � - ----------Title ------------------------------- <br /> (If <br /> ----------------------- - --(If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> 176) <br /> APPLICATION ACCEPTED-'BY _ =- =-=------------=--------------------------------- DATE `_r -' �---,� . . -- <br /> BUILDING PERMIT ISSUED -------------------------------------- ----- ---------------------------------------------- --------------DATE ------------------------------------------- <br /> ADDITIONALCOMMENTS -------------------------------------- ------------------------------------- ---------------------------------------------------=--------------------------- <br /> --------------------------------- ---- ------------ ---- ----- ------------ <br /> ---- _ --------- - ----- - ----------------- -------------------- <br /> ---------------------------------- <br /> - - --------- ----------- -- - <br /> Final Inspection by: G'i �� ------------------------Date -------------------------------------------- <br /> SAN <br /> ------------�? _' � -- <br /> - ---------------------------------------------------------- - -- ---------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />