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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> f (Complete in Triplicate) <br /> Permit No: .7. -�-- ---. <br /> Date Issued -3-- -:-7 v <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 /> JOB ADDRESS/LOCATI �-- :--- - ---- CENSUS TRACT <br /> Owner's Name ------ --- ------------ ----- -- ----------- -- ----- --- ---- ---Phone ------------------------------ <br /> Address /� ------ - -------- -- -- -- ----- ----------- Y --- ----------------------------------- .... <br /> _ 11 �;t <br /> Contractor's Name + --.Licen40 4 se # -------- Phone --------------------- <br /> Installation will serve: Residence X Apartment House[] Commercial ❑Trailer Court ;❑ <br /> Motel ❑ Other -------------------------------------------- <br /> Number <br /> ------ ----------------------Number of living units:------(---- Number of bedrooms -._9---.Garbage Grinder ............ Lot Size ---_�Y --------- ------ <br /> Water Supply: Public System and name ---------------------------------------------------- - --------------------------------------------------------Private '' <br /> Character of soil to a depth of 3 feet: Sand'F] Silt❑ Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam Pq <br /> Hardpan ❑ Adobe'❑ Fill Material ------------ If yes, type _--_--------------_-_--__--- l i <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) 111 <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) i <br /> PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] Size------------------------------------------------ Liquid Depth ----____---_--___--_-_--__ <br /> Capacity -------------------- Type -------------------- Material---------------------- No. Compartments -----------------=•--- <br /> Distance to nearest: Well ------------------------------------Foundation --__.-----------_----.Prop. Line ---------------------- <br /> LEACHING <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 [ j Depth -------------------- Diameter ---------------- Number _-_--------.---------------- Rock Filled Yes ❑ No 0 <br /> Water Table Depth ------------------------------------------------Rock Size --------------------------- <br /> Distance to nearest: Well -----------------------------Foundation -------------------- Prop. Line ............._-_-_---_ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ------..--------------------------) <br /> SepticTank (Specify Requirements) ----------------------------------------------------- -------------------------- ---------------------------- --------------------------- <br /> Disposal Field (Specify <br /> Requirements) _____ JF <br /> ", "J ______ _________________ * ^- --_________ <br /> - -- <br /> r ------------------------------------------------------•----------- <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 /> - --- --- - ff- ----- <br /> BY ------- ------------- ------------------ - - "e T4t.le --- .�► ._,. <br /> - ------------------------------------- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY - - -C(..1i.------------ ----------------•---------------------------------- DATE •------------------ <br /> BUILDINGPERMIT ISSUED ---------------------------------------------------------------------------------------------------------DATE - - -------- ----------------------------- <br /> ADDITIONALCOMMENTS -----------------------------------•------------------------------------------------------------------------------------------------------------------k- <br /> -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -- ----- <br /> ---------------------------------- -- ---- ----------------------------------------------------------------------- --------------------------- <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 />