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FOR oFr=1cE USE: " ' <br /> APPLICATION FOR SANITATION PERMIT <br /> _0 aPermit-Vo. 9: <br /> (Complete in Triplicate) ,? <br /> ---_----------------------------------------- ----------- This-Permit Expires 1 Year From Date Issued <br /> Date Issued <br /> Application is hereby made to the Son 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/LOCATION . / ------------------------------------------ ----.-CENSUS TRACT -------------------------- <br /> Owner's Name e------ h , ---Phone ------------------------------------ j <br /> Address1' -e'A - ---- -- ----- -------------------------------•--- City ------------------------------- ----------------•- ----------------------•- <br /> Contractor's Name --V-------- <br /> - ------------------------------------License # __t ,� Phone 'tC _ <br /> 0� <br /> Installation'will serve: Residenceartment House❑ Commercial:[]Trailer Court iQ <br /> Motel ❑Other----------------------------- ------ <br /> Number <br /> ----Number of livingunits:---- Number of bedrooms = __.__Garb ge Grin r _/L __ Lot Size _ <br /> / Ct t� -------•---•- <br /> Water Supply: Pblic System and name ------0 -//-"�-r-.----- fid-- -•�� ------------------------------Private ❑ <br /> Character of soil to a_depth of 3 feet: Sand'E] Silt❑ Gay ❑ Peat❑ Sandy Loam ,E] Clay Loam ,E] <br /> Hardpan ❑ Adobe i 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: (Nojseptic tank or seepage pit permitted if public sewer is available within 200 feet,) ' <br /> PACKAGE TREATMENT SEPTIC TANK T I Size------------------a________-________--__--_--- Liquid Depth _________________________- <br /> Capacity ------!------------- Type ____________________ Material---------------------- No. Compartments \ it <br /> Distance to nedre'st: Well ------------------------------------_____Foundation ______________________ Prop. Line _______________.__--__ <br /> LEACHING LINE ( ] NO.'of Lines ------------------------ Length of/each line---------------------------- Total Length -------------------------- <br /> 'D' <br /> -----------------•------'D' Box ------------ Type Filter Material ____________________Depth Filter Material -----------------------------.-_____---.__.. <br /> Distance to nearest: Well _________r_____________ Foundation ------------------------ Property Line. ----------.............. <br /> SEEPAGE PITDe th ____________________ Diameter ----------­---- Number -_._-____-.-----._----_ _ <br /> - _ Rock Filled Yes E] No 0 <br /> � ] P <br /> Water Table Depth ---------------------------------4 ,_-_--Rock Size ________________________ <br /> N � <br /> Distance to nearest. Well ------------------------------------ .Foundation -------------------- Prop. Line -- •__••--..-•__-- <br /> REPAIR/ADDITION(Prev. Sanitation Permit e# ___________________________________________ Date ---------------------------------- <br /> 4 <br /> _______--___________ _# Septic Tank (Specify Requirements) ------------------------ - ------------------ - ---------------- <br /> r <br /> Disposal Field (Specify Requirements) ------- -- -- ----- -____- -- - <br /> -------- ---10C,_*- t-- -- -- -_--- <br /> -------------- � �j- `;g y '�! - '------------------------------------ --- <br /> jl <br /> ------------------- ----------- -------------------------------------------------------------------------------------------------------------- ------------------------------- <br /> --------------------------- <br /> A (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 Compe s tion laws of California." <br /> Signed " Owner. <br /> By - 4 ------------------------- Title <br /> (If of than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY _--f e-- -----�r3 Y- --a--- -- ---------------------------------------------------- DATE --- <br /> BUILDING PERMIT ISSUED -:'-'---------------------------------- ----- ------- ---------------- -------DATE ------------------------------- ----------- <br /> ADDITIONAL COMMENTS -- -------- ------ -------------------- ---------------- ---------------- -- <br /> ---------------------------------- ---------='----------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> -------------------------------------------- - ----------- <br /> ------------------------------------------------------------------------------------------ <br /> ------------------------------------------- -'- ---- <br /> Final Inspection bY: - = ------ :------'`----------------------------------Date <br /> h SA OAQU LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M :'a '• , <br />