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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> .............. ......11................... Permit No, -..7............. <br /> (Complete in Triplicate) <br />............... ................................... This Permit Expires Yea From Date Issued <br /> Date Issued ..5 <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 ..wsC ..__ ..:.1"!._. . .... �� ......CENSUS TRACT ..............:........:. <br /> Owner's Name ,Ad't'7�?!L_.. ��_..,. 1L �-�--- ----- -- --J_-._-__--_--._--- -_----___-_.Phone •....................... <br /> Address -....c � .... .f-1 c.U.?Gt-! . .••�• -- . .................................. City ----�--O_jp-�---...............:...:---.........------....._.......-- <br /> Contractor's Name . = t:,c• `. .- :License # = ::_ Phone . <br /> Installation will serve: Residence ,_,Apartments Commercial Trailer Court. <br /> LI P � ❑ <br /> Motel ❑Other --=----=--=--------=--- ---- <br /> Number of living units:............ Number of Bedrooms ............Garbage Grinder ____________ Lot Size ......................................... <br /> Water Supply: Public System and name ..... ............ ............Private <br /> Character of soil to a depth of 3 feet: Sand It❑ Clay ❑ Peat❑ Sandy Loam {] Clay Loam <br /> Hardpan ❑ Adobe ❑ Fill Material ............ If yes,type ............................ <br /> Z(Plot plan, showing size of lot, location ofsystem 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 ] Size.........:...:.................................. Liquid Depth .......................... <br /> Capacity .-..-------•--- .... Type -•....:............. Material_--_----------- -•-• No. Compartments ....................... <br /> Distance to nearest: Well <br /> w ..............Foundation ............... Prop. Line ...................... <br /> LEACHING LINE [ ] No. of Lines ------------ Length of each line---------------- --- Total Length. ............................ <br /> 'D' Box - Type- Filter--Material .•-- 'Depth filter Materiel ................ <br /> s } <br /> Distance to nearest: Well .......................r..... Foundation `w.... Property Line <br /> SEEPAGE PIT' ( ] Depth .....:.............. Diameter .:..::.:.:::..: Number :....•.......:..:...._. __.. Rack Filled Yes ❑ No C] <br /> } m <br /> Water Table—Depth ...........Rock Size <br /> Distance to nearest: Weil _________________ <br /> --•--------•-•---.._._.Foundation .......... Prop. Line ......................� <br /> REPAIR/ADDITION{Prev. Sanitation Permit# :..:... ........::...................:... Date ...t_:-----------------;............. <br /> R <br /> Septic Tank (Specify Requirements) -•--,---_.............................••---•-::---- ------' <br /> �. ........,_....t.S-------- . o•-...t___. _ . <br /> �Disposal Field (Specify Rnts) Ft � � ....e uireme ...............k -..---• •-•--•-•------- <br /> p <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 I <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District:fiome owner or licen- <br /> sed agents signature certifies the following: . t <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 subjectto orkrnan's Compensation laws of-California." <br /> Signed / <br /> ._......... ......... Owner ---�---� ' <br /> By .......... .ter .,�.�z•C ..1..''?� �// x __- Title -4................................ --------------------- ............... <br /> (if other than owner) -t <br /> ODEPARTMENT USE ONLY -} <br /> APPLICATION ACCEPTED BY ...... . .. ..... .. ... ..... �.... ........-................. ................................ DATE .............. <br /> y' . i BUILDING PERMIT ISSUED <br /> ADDITIONAL COMMENTS ....... .........�----...__./ r.......... ..",.ZTc <br /> ?e ........l ...... <br /> t �....... <br /> ,. <br /> ..................................................................................................................--,-_...................................................._.......................I....... <br /> ........................... .... .... ................................. <br /> Final Inspection ......... <br /> ... <br /> .............. - 'i ` :'.fid <br /> SANJOAQUIN LOCAL HEALTH DISTRICT r� <br /> E. H.L3 24 1.'68 Rev. 5M 7/7;'J M � <br />