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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> - ---------------- --------- -•------- ---______ Permit No. <br /> (Complete in Triplicate) <br /> ---------- ------- --------------------- ---------------- <br /> Date Issueds_�---�-- <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 /> DQ 5 �.I�iN- ` `� --CENSUS TRACT ---- - .._. <br /> JOB ADDRESS/LOCATION .---------��-� C-------�IAM-_ J Q� <br /> Owner's Name -------------- Ml ei1------ ll_/Yl1 II__�--------------------------------= --- Phone--- --------- ---- --- ---- <br /> Address v --- Cit mw*&G --------------------------- <br /> �.���- ------!rV/1//�fc� y <br /> Contractor's Name -------------19---------cl�------------------=--------License # ---------:-------------- PhoneOC7;)3 <br /> Installation will serve: Residence X]Apartment House[] Commercial:❑Trailer Court ;❑ <br /> Motel F-1 Other -------------------------------------------- <br /> Number of living units:----- Number of bedrooms _�------Garba_ge Grinder ------------ Lot Size rk -------• <br /> Water Supply: Public System and name ------------------------------------------------------ <br /> -------------------------------------------------------Private E]Character of soil to a depth of 3 feet: Sand'p Silt❑ Clay ❑ Peat❑ Sandy Loam •❑ Clay Loam .E] <br /> Hardpan ❑ Adobe ❑ 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: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] Size------------------------------ •-- - Liquid Depth -------------------------- - �r <br /> Capacity ---- --------------- Type ------------- ------ Material---------=------- ---- No. Compartments --------- ------------ <br /> Distance to nearest: Well ----------- -----------------------Foundati n __.------------------- Prop. Line ------.--- ------ 0 <br /> LEACHING LINE [ ] No. of Lines ------------------------ Len th of each line---------- ----------- ----- Total Length ------------------------_-__ 0 <br /> 0 <br /> 'D' Box ------------ Type Filter Ma rial --------------------Dep Filter Material --------------------.----------- ---•------ <br /> Distance to nearest: Well ______ __._______-- Foundatio _______________-_------ Property Line ______________--------- <br /> SEEPAGE PIT Depth _ Diamet r ________________ Numbe ____.____-_-----.__________ Rock Filled Yes ❑ No 1❑ , <br /> WaterTable Depth ---------- --------------------------------- ---Rock Size -------------------------------- <br /> Distance to nearest: Well ---------------------------- <br /> ---- -------Foundation _----------- ---- Prop. Line -----------------_-- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# --- ---•-------------------------- --- Date -___---_-----------------.---_-_--) <br /> r " <br /> Septic Tank (Specify Requirements) -------------------- -------------------------------------------------------- ------ <br /> bisposal FieldV(Saify Requirements} ___________ __ <br /> - ---------- -- - ------------------------ --------- <br /> -------------- ----------- ---- - <br /> -- -----------��--`----- �►-�,� ii,% , s <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 /> I as to become subject to Wor an's Compensation laws of California." <br /> Signed Owner <br /> BY t Title <br /> ---------------- ----------- - --------------------- - <br /> {lf other than ned <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -------7—t-Ar:01----------------------------------------------------------------- -------- DATE ------- �5"-Z_3------------- <br /> BUILDING PERMIT ISSUED ---------------------- -------DATE ------------- ------- ---------------- <br /> ------------------------------------------------------------------------- <br /> ADDITIONAL COMMENTS ------- -- ------------------------------------------------------------------------- <br /> - - ----------------------------------- ---- -- ---------------------- <br /> ----------------------- <br /> = ------- - - - ----------------------------------------------------------------------- <br /> i <br /> -------------------- -------------------- --------- ------------------------ -- - ------- ----- -- ----------------------------------- <br /> - ---------- -- ----------- <br /> Final Inspection bY- ----- - ----------- -- -----.Date ---------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />