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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ---- -- ------ ----------- ---- ---------------------- <br /> (Complete in Triplicate) Permit No. __.7. --_ ------ <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 per 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 -------- -------U-017—S4: 7- .L- ---------------CENSUS TRACT -------------------------- <br /> Owner's Name ----- -----------C-Q--kR-F-11f------------------------ ----------Phone <br /> Address ---------- ------------------------------------------ -------------------------------------------------- City -- ------- ---- ----------------p---------------------------- <br /> Contractor's Name ._E __.W--- -------- --------License --_ Phone <br /> Installation will serve: Residence VApartment House❑ Commercial ❑Trailer Court ;❑ <br /> Motel ❑ Other --- ----------------------------- <br /> Number of living units:---/------ Number of bedrooms __�---_Garbage Grinder ---,/------ Lot Size //S-----X----/-.2-- -_..._ <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 ---------------------------- 1A <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,) I <br /> PACKAGE TREATMENT [ I SEPTIC TANK f ] Size------------------------------------------------ Liquid Depth ---�f'� ------------- <br /> Capacity J -_.---_ Type -�► t"%4%* <br /> Material - No.i Compartments _---'_„ .............. <br /> Distance to nearest: Well -_-_ _____ ---------------Foundatibn ___._� - ....... Prop. Line --- -___________-_ <br /> L�AGi,i4A1COwE [ ] No. of Lines dW ------- Length of each line-_---— --------------- Total Length Q. ............ <br /> ' 'D' ..Box ___ �_ Type Filter Material ____Depth Filter Material ___ 1 <br /> ---------------- <br /> Distance to nearest: Well ------- Foundation ____ <br /> /� r <br /> �Lr_ ._ ______ Pro a Line <br /> SEEPAGE PIT [ ] Depth -------- ----------- Diameter ---------------- Number --------------------- ------ Rock Filled Yes ❑ No ❑ <br /> Water Table Depth ---------'--------------------------------------Rock Size -------------------------•------ <br /> Distance to nearest: Well ----------------------------------------Foundation ---------- ------ Prop. Line --------- ------------ f <br /> REPAIR/ADDITION(Prev. Sanitation Permit# _______..________________________ ---------- Date -------------------,______________) <br /> SepticTank (Specify Requirements) ---------------------------------------------------------------------------------- ---------------------------- ---------------------------- <br /> Disposal Field {Specify Requirements) -------------------------------------------------------------- <br /> -------------------------------------------------------------------------------------------------------------------------------------------•-------------------------------------_-------------••--------- <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 mpensation laws of California." <br /> Signed -------- ---------- --------------------- Owner ' <br /> BYTitle --------------- ------------------------- <br /> (If <br /> ------------------------- <br /> -------- ---- ------------------------------------ <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ------------ ----------- -_ DATE __.__-.-_._.-------_._ ._ <br /> --- ----------------------------------------------------------------- � - ------------------ <br /> BUILDINGPERMIT ISSUED ------------------------------------------------------------------------------ --------------------------DATE ------ ----------------------------------- <br /> ADDITIONALCOMMENTS --- -----------------------------------------------------------------------------------------------------------------------------------------•---------------- <br /> --------------------------------------------------------- ------------------------------------------------------------------------------ -------------------- ----- <br /> -------------------------------- --I------------------------------------------------------------------------------ - - _ ` <br /> FinalInspection by: ------------------------------------------------------------------------- ----- -- --------------------------------Date ---. . J <br /> SAN JOAQUIN LOC ALTH DISTRICT r <br /> r � <br /> E. H. 9 1-'68 Rev. 5M G <br />