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`FOR OFFICE_USE: <br /> - ----- ----------- --------------- �T �; •-- —APPLICATION FOR SANITATION PERMIT <br /> ' -------------- (Complete in Triplicate) Permit No: <br /> ------ ----- ------------ This Permit Expires 1 Year From Date Issued Date Issued <br /> Application is hereby made to the San Joaquin Local Health District fora <br /> describconstructe work <br /> - <br /> ed. This application is made in compliance with County Ordinance Na. 5490and ex st ngnRulestalndt Regulat onsrein <br /> I <br /> JOB ADDRESS/LOCATION <br /> ` ----��?�ITG. %t - ----------------- -CENSUS TRACT <br /> Owner's Name ; 3 <br /> ---------------- --- <br /> Address ------------ 6— r" <br /> --- -------Phone -- - - <br /> ----- --- ------------ Cit <br /> Contractor's Name ----_---_---__-___ --------------------- <br /> --- P •X 1 -------.License #� /i Phone`���' 6 -7 <br /> Installation will serve: Residence�<Apartment House-E],Commercial : TrailerCourt iF-1 <br /> Motel ❑Other --------------- <br /> -------------------- <br /> Number of living units:-- -_------- Number of bedrooms!- -_-� <br /> -_--Garbage Grinder ------____-- Lot Size ---�--------------- --- <br /> - -------------- <br /> Water Supply: Public System and name ---------------- ------- <br /> ------------------------ Private <br /> Character of soil to a depth of 3 feet: Sand.'E]/Silt❑ j Clay [:1 Peat❑ Sandy Loam .E] Clay Loam <br /> Hardpan [] Adobe t� Fill Material ......... If yes,type ----__------_--_-- <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: 4 `%, <br /> (No septic tank o`r seepage pit permitted if public sewer is available within 200 feet,) \) <br /> PACKAGE TREATMENT [ ] SEPTIC,TANK Size--- <br /> __f -r------- . ---- Liquid Depth --�.��-'- <br /> -r- Ilk <br /> -----.-.--- <br /> Capacity W- TYpe --Material-- No. Compartments <br /> Distance to nearest: Well ------ --------Foundation --_- ____-_- Prop. Line - ✓� "y` <br /> LEACHING LINE No,,of Lines _--_- -._ _-- <br /> � g -- --`�h~line--'-"�',5--- ---._ Total Length .----f T�---- - <br /> - - -------- <br /> 1 <br /> Length of.eat .�. <br /> D' Box --_----.✓_ ,ype Filter Material _'� / <br /> ,j �+;-� r r --- -- .Depth�Filter Material -----f-- ---------------•---------•-----• <br /> Distance to nearest, Well ------0- ,__,__--Foundation <br /> ---------------------- <br /> SEEPAGE PITDepth, Z _-__--- Diamete`r' �'___ Number 1. 7--____--_____- Rock Filled Yes�K No .i0 <br /> Water Table .Depth -------------------------•------------- -------Rock Size�- <br /> A ; <br /> • ` ' ..Dis#ante to nearest: Well --------- -(JL?-------'!"----------Foundation __!1 - ------- Prop. Line ---,5................ <br /> REPAIRCA�DDITION(Prev. Sanitation Permit�# --------------------- ---------------------- Date --------------- <br /> Se �------_---------_-) <br /> p Tank (Specify Requirements) ------------------- ,-----------_----_---------- <br /> ------------------------ <br /> Disposal Field (Specify Requirements) ----------------- ---- ?;�'` I <br /> `::----;---------------------------- -------------------------------------------------------------- <br /> ---------- <br /> ------------------ <br /> --------------- - <br /> ------------------------ -- <br /> ------------------------------------------------------------------------ <br /> �� (Drawexisting and required addition on reverse side) <br /> I hereby certify that 11 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 - -- -- -- ----- ` - -------- ---------- ............ <br /> --------- - Title --- _ <br /> s - _? ------------------------------------------ <br /> (If other an owner) 0 <br /> FOR DEP"TMENT USE ONLY <br /> APPLICATION ACCEP D BY --__- <br /> ------------------------------- <br /> --- -------------- DATE ---- --fir /^=• -Z <br /> BUILDING PERMIT 1S LIED ______________ _F ____ ------------ <br /> ADDITIONAL COMMENTS ---------- � -------------------------------------- DATE <br /> ----------- <br /> _.:;r -------- - ----- <br /> --------------- ------------ <br /> ---------- <br /> ,-- - <br /> ---- - ---- ---- ------- ---------'-"� - ------------------------------------- <br /> --------------------------------------- <br /> -- ----------- --------------------------------------------------------- -------------- <br /> Final Inspection by: -- ` ,L <br /> - ------------------------------Date --- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />