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FOR' OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ______ ________ ________________ Permit No. <br /> (Complete in Triplicate) l <br /> -------------------------_---------- This Permit Expires 1 Year From Date Issued <br /> 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 Couty Ordinance No. 549 and existing Rules and Regulations: <br /> ''// <br /> JOB ADDRESS/LOC ON ---3-T---3- '1�+.1---- "-' ----------.CENSUS TRACT -------------------------- <br /> Owner's Name -- -- ----- - -- -- ----•----- -----------------•- ---- - --- <br /> ---Phone ---------------------- ------------- <br /> ----->1---� --- -- --- City --- ---- --- - - ---------------------------------- ---------•------ <br /> Contraetor's Name ---=-------.License # _1_ p3??71hone ------------------------------ <br /> ---- <br /> Installation will serve: Residence Apartment House�❑ Commeerr '.al ]]Trailer Court ;❑ <br /> Motel ❑Other' __`�/'�" `�`'� '�-------C�g z"L <br /> Number of living units------ Number of bedrooms --_-7`---Garbage Grinder ----____-.-- Lot Size ___--�i ------------------ ----------- <br /> Water Supply: Public System and name -------------------------------•-----------------------------------------•------------------------------------Privatek <br /> Character of soil to a depth of 3 feet: Sand'o Silt❑ Clay ❑ Peat❑ Sandy Loam 'D Clay Loam ❑ <br /> Hardpan Adobe ❑ Fill Material --------- -- If yes,type ----------------___--- <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. most 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 ----------------.:.... 6 <br /> Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line -----------------...... Z <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 /> PIT [ ] Depth -- Diameter _-__----- Rock Filled Yes No U <br /> Number ❑ �❑ 0 <br /> Water Table Depth ---------- -------------------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line -_------------------ <br /> REPAIR/ADDITION <br /> _--------------_ •-REPAIR:/ADDITION(Prev. Sanitation Permit# ------------ ------ Date ----------------------------------) <br /> Septic Tank [Specify Requirements] ------------- - ----------------- ---------------------------------------------..--•------------------•---------- <br /> ------------------------- - <br /> isposal Field (Specify Requirements] - ----- ------ --- �^- ------ F--- ----- z------------- <br /> �--- - -joP . ---- ---- ------- <br /> ------------- <br /> --- --- ------------------- ------------------ .. �Y ------ <br /> P---- <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, 1 shall not employ any person in such manner <br /> as to become subject to VAdfran's Compensation laws of California." <br /> Signed Owne <br /> ----- - itl mk <br /> -W44� <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED B -- --------------------------- ----------------------------------------------- DATE ------------- <br /> BUILDINGPERMIT ISSUED ----------------------------------------------------------------------------------------------------------DATE -------------•----------------------------- <br /> ADDITIONALCOMMENTS ------------- ---------------------- ----------------------------------------- --------------------------------------------------- --------------------------- <br /> ---------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ------------------------------- --------------------------------------------------------------------------------- ------------------------ <br /> ---- <br /> - 'a -�_ <br /> Final Inspection by: - ------`---�------- - -- --- --- -------- ---------------• --------------------------------- <br /> --Date � --------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9- 1-'68 Rev. 5M <br />