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FOR OFFICE USE. APPLICATION FOR SANITATION PERMIT f <br /> (Complete in Triplicate) Permit No. <br /> This Permit Expires 1 Year From bate Issued Date Issued Application is is hereby made to the San Joaquin Local Health District for a per to construct and install the work herein <br /> described. Th_iis� application.is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS�LOCAT EO S/ Y__d44_fJ-_dZENSUS TRACT - <br /> Owner's Name ------- -------------------------------------- ---- --------- ff �,..,, Phone ------ <br /> Cit L�---- __ -- <br /> Address. ll , 0 + ; , - ----- -- --------w Y J p -- ----------------------------------- ------ <br /> Contractor's Name --- - .-----, Yl - -------- ---- License # [-�0- --- Phone --------------------.------_ <br /> installation will serve: Rgsidence Apartment House❑ Commercial❑Trailer Court <br /> Motel ❑ Other sl,.-S_ - <br /> Numberof 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'❑ Silt E3 Gay ❑ Peat❑ Sandy Loam Clay Loam E3 <br /> Hardpan ❑ Adobe-❑ Fill Material ------------ If yes, type ____________________________ " <br /> (Plot plan, showing size of lot, location of system in relation to weds, buildings, etc, must be placed on reverse side.) p <br /> NEW INSTALLATION: (No septic tank or see age pit permitted f pubic sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ Size _Xf_-X�_______________________ Liquid Depth ___�'�__._ _.__________ <br /> Capacity -YO-0OAS- Typ - <br /> --_ -_ Material _ _ ------------- <br /> Distance <br /> ' .. <br /> _ No. Compartments - ._.-- .-.____ � <br /> Distance to near st: Well -----------1_a Q_________________Foundation _______0___________ Prop. Line .S________________ ~ <br /> s <br /> LEACHING LINE /No. of Lines -----f------------ -- ,Length of each line "AST._44 Total LengtT, ----Ife_._--_____________ <br /> 'D' Box _'— Type Filter Material ----SA&------Depth -Filter Material ------L:P----------------- --------------- <br /> Distance <br /> _-- _______Distance to nearest: Well ---------+tQa__r_____ Foundation ---------- Property Line --_r ]N <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter _,____________ Number ----- ----------- ------ Rock Filled Yes ❑ No ❑ <br /> Water Table Depth -------------__'___I{---------------------------Rock Size -------------------------------- <br /> Distance <br /> ------Distance to nearest: Well ------------_!_-------------------------.Foundation ___________________ Prop. Line _------_----------- <br /> REPAIR/ADDITION <br /> ---_-- _.___--_ . _REPAIRJADDITION(Prev. Sanitation Permit# -------------------------------------------- Date _________________________________} <br /> Septic Tank (Specify Requirements) -------- ------------------------------------------------ <br /> - <br /> Z ----------------------------------------------- --,­--------------------------- <br /> Disposal Field (Specify Requirements] --------------- <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 sub[ ct Workman's Compensatio ews of California." <br /> Signed ------ - ----- Owner - <br /> BY ---------------------------- -------------- a ------ Title <br /> ---------------- <br /> (If other t an owner) <br /> FOR DEPARTMENT USE ONLY <br /> ------------------------------ - - DATED'_y ` -- --,- <br /> ---------- <br /> APPLICATION ACCEPTED BY <br /> BUILDING PERMIT ISSUED ---------------------------------------------------------------------------------------------------------DATE ...... --------------------------- <br /> ADDITIONALCOMMENTS ---------------------------------------------------------------------------------------------------------------------- ------------ --------------------------- <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ---------------------------------------------------------- <br /> - - ---------------------------------------------------------------------------------------------------------- -------- ---------------------- <br /> ---------------------------------- �.1 -----_------- <br /> Final Inspection by: - ------ ---- -- -------- -- - - - -- Date V -s �1 <br /> v ------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />