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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> ------ ------------ ------- -•------- - - Permit No. <br /> (Complete in Triplicate) <br /> -------- =------------ ------------------------------ qa <br /> •' Date Issued7 <br /> ---- This Permit Expires 1 Year From Date Issued <br /> D 2,3 - t vo-1 2- <br /> Application <br /> Application is hereby made to the San Joaquin Local Health District for a per to construct and install the work herein <br /> described. ibis a.pplicat.ionris,made,in,.compliance with County Ordinance No. 5.49 and existing Rules and Regulations: <br /> u�+4 .y 2 ' <br /> iZ ( 1 2 � :f .C,�1-[. .�j� , _ _ [_1s t{ -.l'�'- S� CENSUS TRACT -.5---------------- I <br /> JOB AbDRESS/LOCATI N t�_________________ 4 <br /> Owner's Name ---------- ----- -------- y <br /> Phone <br /> Address - - - �'.� ��=�`=---- -- City ----------------------------------- ---------------------------------------- <br /> - --------- ----- --- <br /> r 6 <br /> Contractor's Name ---- ''� - - -.------�-----�---.License # --hy- Phane . <br /> Installation will serve: Residence [?rApartment House-F] Commercial ❑Trailer Court ,❑ <br /> Motel ❑Other ----------------- --- ---------------------- <br /> Number of living units------ ------ Number of bedrooms ---Y---Garbage Grinder _.---------- Lot Size .-___------_--------_-------------------- <br /> Water Supply:'Public System and name ---------------------------------------------------------------- ---------------------------------------------Private <br /> Character of soil to a depth of 3 feet: Sand'E-] Silt[IClay FJPeat E] Sandy Loam ❑ Clay Loam [P'" 9 <br /> Hardpan ❑ Adobe ❑ Fill Material ------------ If yes, type ----------------__------- <br /> (Piot 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 f ] SEPTIC TANK'[ ] Size------------------------------------------------ Liquid Depth -_-.-----_----_.._ -_-- <br /> Capacity ---- --------------- Type -------------------- Material---------------------- No. Compartments ------------ --- ---- <br /> Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line <br /> LEACHING LINE [ ] No. of Lines ------------------------ Length of each line---------------------------- Total Length ,-----•----•--------..-•-•-- <br /> 'D' Box ----.------- Type Filter Material --------------------Depth Filter Material ---------------------------------------• <br /> Distance to nearest: Well -------- --------------- Foundation ------ ----------------- Property Line --------- -------------- <br /> SEEPAGE PIT [ ] Depth -------`------------ Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No <br /> WaterTable Depth ------------------------------------------------Rock Size ------- --------------------•--- <br /> Distance to nearest: Well -------------------------------------- -Foundation -------------------- Prop. Line -------------------•-- C <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) <br /> Septic Tank (Specify Requirements) ---------------------------- - ------ -------------- :--------- -------------- <br /> - - ------------------------------ <br /> 4fz <br /> Disposal Field (Specify Requirements) -- ---Q�-��---- '� ------ - 4-----�----- <br /> ------------ ------------.SQ ' -------------------------------------------------- ------------- - -------------- <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 /> Signed -------------------------------------------- ---- Owner _ <br /> BY `----- Title "P`'` ----------------------------- ---- <br /> - ---------------- <br /> l (If other than owner <br /> i <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY - ` ------------------------------------------------ --------------- DATE BUILDING PERMIT ISSUED --------------------- --------------------------- <br /> ----------DATE ----------------------------------------- <br /> ADDITIONALCOMMENTS ------------------------------------ -------------------------- ------------------------------------- --------- ---------------- <br /> - --- --- -------------------------.-.--------------------------------------------------------------- <br /> ---------- ---------------------------------------------------------------------- <br /> i <br /> -------------------------------- ------------------------------------------------------------------- <br /> - <br /> ---- - ------ ---------- -------- -- ---- <br /> ------------------------------------------------------------- ------------- <br /> Final Inspection by � Date -i � <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M. <br />