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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> --------------------------------------------------- ���, <br /> (Complete in Triplicate) Permit No. <br /> ---------- ---------------------- V 26 7f/ <br /> ---------------------_-------------------________________ This Permit Expires 1 Year From Date Issued <br /> Date Issued A."_______'._.. <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/LOCATION -------------Gwie// -----------------------------------------------------CENSUS TRACT -------------- ........... <br /> Owner's Name i <br /> --------------------------------------------i--- -- _P one <br /> Address ----// -- ------------- - - -- --.-�--- ----- ---- ----- --- ------------ City ------------------------------------------------. <br /> Contractor's Name --- -�__ - i.Y� � License # : 7 l__ Phone 1, 5_ SS- _... <br /> Installation will serve: Residence partment House[] Commercial ❑Trailer Court ;❑ <br /> Motel ❑Other ----- -------------------------------------- <br /> Number of living units:__/__-_ Number of bedrooms _ __-._Garbage Grinder ------------ Lot Size ------------------ <br /> Water Supply:Public System and name ----------------------•---------------------------------------------_------------------------------------------Private g -- <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> HardpanE]' AdobeFill 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: (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 _&CZ2------- Type� Material_ - __ No. Compartments _,-2. .............. <br /> Distance to nearest: Well _-- ----------------------Foundation _ACI_____________ Prop. Line 111 ?_........._ <br /> LEACHING LINE [ ] No. of Lines -----�_____________ Length of each e----ks_-______--_- Total Length ___/ ..__.... <br /> 0 <br /> 'D' Box __J------ Type Filter Materials �� li __Depth Filter Material __,�� ........................... <br /> Distance to nearest: Well _ �`Q_1_________ Foundation _____________ Property Line ......... <br /> [ ] p ca------------------ Rock Filled -Yes '(3' No CiiQ <br /> SEEPAGE PIT Depth __�,�-__-____- Diameter -��___.___ Number ______ _ <br /> Water Table Depth ------- ---------------------- .........Rock Size <br /> Distance to nearest; Well __-Z . ------------=---------Foundation / ----------- Prop. Line .A-z)-_........ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ____________________________________________ Date ----------------------------------) <br /> SepticTank (Specify Requirements) -------------------- ------------------------------------------------------------- ---------------------------•-----------------•----------- <br /> Disposal Field (Specify Requirements) ----------- ------------------------------------------------------ -------------------------- <br /> --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------­---------- <br /> --------------------- <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 subject to Workman's Compensation laws of California." <br /> Signed ewned <br /> _____ _. Owner <br /> By ------- ------ Title �---------------------------------- <br /> (If other tha <br /> FOR4DEP#tTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ----- - ...... DATE " ------- <br /> BUILDING PERMIT ISSUED ---- -------- - ----------- ------------------------------------------------ ----DATE ---------------------------- -- .......... <br /> ADDITIONALCOMMENTS -------------------- - --- ----------------------- ---------------------------------------------------------------------------- <br /> ---------------------------------------------------------------------------------- ---------------------------------------------------------------------------- ------------------------------------------ <br /> --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> -------------Al" 1- 1 ----- - - - - - - - - - - } <br /> FinalInspection by: ------------------------------------------------------ ..---------------------------------------Date -----q---1 - - ----------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />