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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> _........ (Complete in Triplicate) Permit No. . T/-__7 � <br /> .................... —----------------- . - This Permit Expires I Year From Date Issued �} <br /> - 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 compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION ,..1 .....38 ` C /pr,i <br /> .....................................CENSUS TRACT <br /> Owner's Name ..........._..... <br /> Address :. Phone <br /> ................................ ..............•-••--------•-•----••- <br /> City .........................Contractor's Name <br /> ........................................... <br /> Installation will serve: <br /> �/ --------------------- <br /> ------------------ --------License # .�_1�t ..... Phone <br /> Residence [Apartment House❑ Commercial ClTraller Court <br /> Motel ❑Other <br /> Number of living units.-..--------- Number of bedrooms ._..._..__-------Garbo a Grinder _...._ <br /> Garbage Lot Size -------•-•--•.................. <br /> Water Supply: Public System and name ........ .. ... <br /> ; Sand❑ Silt Cla Private ❑ <br /> Character of soil to a depth of 3 feet <br /> ❑ Y ❑ Peat❑ Sandy Loom ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe ❑ Fill Material ............. Ifes ` <br /> Y , 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,} <br /> PACKAGE TREATMENT [ ] SEPTIC TANK <br /> Size.. <br /> - <br /> •- ----••- Liquid Depth ..-•-•--......-------------- <br /> Capacity <br /> � <br /> •-- YPV& ..... Material. o � . <br /> No. Compartments <br /> Distance to nearest. Well 00 <br /> ------_. Foundation ..f-----•----- Prop. Line ..--.C.7.5•••-- 09 <br /> LEACHING LINE [ No, of Lines <br /> ----_...----•----•------ Length of each line.----`5�"�4'4 <br /> 'D' Box ---•• Total Length ........... <br /> Type Filter Material - Dep#h Filter Mater€al ._.._...1 .`�. .. / 1' <br /> C <br /> Distance to nearest: Wel! 'f ---... Foundation .. . <br /> SEEPAGE AIT • •••-••-•--- Property Line _���„ <br /> f ) Depth .................... Diameter Number ......................•------- Rock Filled Yes [) No C3Water Table Depth ................... ....Rock Size -•.............. �I f <br /> : Well ...... <br /> Distance to nearest ....................Foundation ------....__. <br /> -•-•-••.. Prop. line <br /> REPAIR/ADDITION(Prev. Sanitation Permit <br /> ..........." <br /> P <br /> { # ..............:... - ------------ Date } <br /> •-•-----•--- <br /> Septic Tank (Specify Requirements) ......... --- <br /> ............. <br /> ----•- ------------------- <br /> isposal Field (Specify Requirements) <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 an- <br /> "I <br /> agents signature certifies the following; <br /> "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person In such manner <br /> as to become bfec to Workman's Compensation laws of California." <br /> Signed ' <br /> ) -- <br /> -- . i._ Ownet <br /> •..... ............•....--- ......---...-•--- •. <br /> By _..._._.. • ... ....... ... Title -._'_.. <br /> .......................••-•-•. -•----•. <br /> (If other than owner} ...................................................... <br /> �= FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY .............. <br /> ._ ..... .. ----• •- ......................-..............-....................... DATE ....... <br /> BUILDING PERMIT ISSUED ............. �.'.-.�. ... <br /> ��..-•-- <br /> ..... <br /> ..._ <br /> DITIONAL COMMENTS DATE <br /> ......................• ........................ <br /> Final Inspection b - ......................................................... <br /> -------------------------------------------------------------Date ---.fQ.. ........... <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H.1.3 24 1.'68 Rev. 5M <br />