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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ;Complete in Triplicate) Permit No: <br /> Y.; <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 . a �'�f4 ��. ..... -qW- 3----------- --11?AC.Y- ----------CENSUS TRACT -------------- ----------- <br /> Owner's Name }�2r1 �� <br /> -- -------- n--------1��_-TZ.--------------------------------------------------------- ---- Phone ----.. <br /> Address ----------------------- ----- ------ ---------------------------------------------------------------------------- City ----- _aAGi--------------------- <br /> Contractor's Name ------------------C.= ------------------------------------------------License # -------- --------------- Phone --------------------------- <br /> Installation will serve: Residence ❑Apartment House❑ Commercial ❑Trailer Court i❑ <br /> Motel ❑ Other -------------------------------------------- <br /> Number of living units:__________ Number of bedrooms ____________Garbage Grinder ____________ Lot Size ___________________________________.._..-_. <br /> Water.Supp[y: Public System and name --------------------------------•------------------------------------ ----------------------------- <br /> Character <br /> -------------Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam 'E] <br /> Hardpan ❑ Adobe.I] Fill Material ------------ If yes, type ---------------------------- <br /> (Plot <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,] <br /> PACKAGE TREATMENT [ ] 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: We11 ______________ __' Foundation" "'____________________ Property 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 ___.____--________..__ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ___________________________________________ Date __________________________________) <br /> Septic Tank (Specify Requirements) -------- ----------------------------------------------------- - <br /> ------"I----------------------- <br /> Disposal Field (Specify Requirements) ------- ------ 1 - •--------------------- ------ Cq,! <br />.- r -------------- <br /> ---------------------------------_ T T_ _ v --;;;._ V -4-- -;-�---------------- <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: Y <br /> "I certify the in the performance of the work for which this permit is issued, I shell not employ any person in such manner <br /> as to beco a su cAtorkman's Compensation laws of California." <br /> Signe --- ------------------------------------------------------------- Owner <br /> By ------- Title <br /> ------- ------------------------------ <br /> --------------------- <br /> ther th n o er) <br /> FOR DEPARTMO4, USE ONLY <br /> APPLICATION ACCEPTED BY DATE -- �d '�� <br /> BUILDING PERMIT ISSUED --- ----}--------------------------------------------------------------------DATE ----------------------------------------- <br /> ADDITIONAL COMMENTS --- --------- -- ---------- -- <br /> ----------------------------------------------------------------------- --------- ---------------------- ----------------------------------------------- <br /> Final Inspection by: ------------------ --------------------------------------------------------------------F------.Date <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />