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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> -------------------------------- fl-------- Permit No.. <br /> (Complete in Triplicate) ..,� <br /> ------- ----------------------- `� --,-------- <br /> Date Issued <br /> ,j,- <br /> ----- This Permit Expires 1 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 compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOS ADDRESS/LOCATION ---- -y- �W--------- ---------------CENSUS TRACT ---------.----•----------- p <br /> Owner's Name -----=- ------- Phone i <br /> ---------------------•---------------- <br /> Address ----- -----------tP- /�_e------------ ----------------�---'-- City /L � * ; <br /> Contractor's Name ---- - i�-V�(('��'- "-- 1--=--------License # -4p - ��- <br /> .' Phone -/---' <br /> If <br /> Installation_ will serve: Residence XApartment House C❑ Commercial :❑Trailer Court C] so <br /> # Motel ❑Other ------- ---------------------------------- <br /> Number <br /> ---=----------------- ----Number of living units:_.__ __ Number of bedrooms __. -----Garbage Grinder -�� Lot Size, _ -; ----------- <br /> Water Supply: Public System and name ---C-dv/-, ----- f�----%, ',ev evoe_ °d---------------- ---------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Q Clay ❑ Peat❑ Sandy Loam -❑ Clay Loam <br /> Hardpan ❑ Adobe' Fill Material ------------ If yes, type _-_----------------------- <br /> 4 <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 ik it permitted if public sewer is available within 200 feet,) <br /> 4 septc tanor seepage p ' <br /> PACKAGE TREATMENT [-] . SEPTIC TANK:[ ] ,�Size--------------------------=--------------------- Liquid Depth ---------------------.----- b\ <br /> r CppacitY ---------------- -- Type -------------------- Material---------------------- No. Compartments -----_-------- = <br /> sDistance to nearest: Well ------------------------------------Foundation ----------------------.Prop. Line -----------..--------- <br /> LEACHING LINE- [ ] a No. of Lines -------------- `-; `'Length of each line---------------------------- Total Length .:____-_____.__..-..-------- <br /> ..A._ <br /> � v'_.t <br /> D Box ___- Type.Filter Material`--------------------Depth Filter Material -----------------------------•.............. <br /> Distance to nearest: Well ------------------------- Foundation Foundation .___.-__------ ________ Property Line ________--_.....___:.__. <br /> SEEPAGE PIT [ ] Depth ---------.---------- Diameter ________________ Number ---------------------------- Rock Filled Yes ❑ No 0 <br /> WaterTable Depth ------------------------------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well --------------------- ------------Foundation -------------------- Prop. Line ----•.---------------- .. <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) <br /> Septic Tank (Specify Requirements) s� �---------- ----- <br /> Disposal Field (Specify Requirements) _____-4- ---- ---1.---'- 1 <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 /> x <br /> as to become subject to Workman's Compensation laws of California." <br /> t <br /> Signed ------- ---------------------------�-�-------- Owner <br /> ------------------------------ Title --- <br /> ---= I ;-------------- <br /> t <br /> er than owner} <br /> I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED l3Y` ` vW------------------------ DATE _ �' <br /> BUILDINGPERMIT ISSUED ------------------------------------------------------------------------------------------=--------------DATE ------------------------------------------- <br /> ADDITIONALCOMMENTS------------------------------------------------------------------------------------------------------------------------------------------....----------------- <br /> ----------------=--------------------------------------------------------------------------------------------------------------------------------------------------------------------- --------------- <br /> ----------------i--------------------------------------------------------------------------------------------------------------------------------------------------------�_---------�--------- <br /> --- ------------------�------------- - ==- <br /> ----- <br /> .----- - Date zS <br /> FinalInspection by: -- --�----------------------r'---�-- .._- ---------------------------------'--------------------------------------- � ----- ------------ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M. �y ' <br />