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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> .. ..w <br /> Permit No. 7�-/ <br /> (Complete in Triplicate) ------ <br /> ---"=----------------------------------------------- <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 County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION - - --- -f------- ---- -------- ---------CENSUS TRACT -----------------•------ <br /> Owner's Name �F= �{� ------ -- ---Phone <br /> --- <br /> Address -------- a -� City <br /> Contractor's NamefJf - ---------------- ----. -------License # jg-/V;_� 9_ Phoned . <br /> « r <br /> Installation will serve: Residence XApartment House-0 Commercial :❑Trailer Court ;❑ <br /> Motel F❑ Other -------------------------------------------- <br /> Number of living units.-_/----- Number of bedrooms --A Garbage Grinder /(,P__ Lot Size --------------- <br /> Water Supply: Public System and name ---------------------------------------------------- ----------------------------------------------------------Private <br /> Character of soil-to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam -❑ Clay LoamA <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__ _. ;)<I%ef- _______----------- Liquid Depth <br /> Ca acit Type ,( <br /> Material , -___ No. Compartmentster.........:.... <br /> Distance to nearest: Wel -----, ------------------Foundation ------------ Prop. Line+_--______._____ <br /> LEACHING LINE No. of Lines _/__________________ Length of each line_ . _________._._--- Total Length ...._.........__.. �' <br /> ff, � <br /> 'D' Box _��_._ Type Filter Material/��t, Depth Filter Material__________________________________ t <br /> .�r <br /> SEEPDistance to nearest. Well 1_____________`ou cla`ion ?__�__________ Property Line __________.:.___ <br /> A l Depth / _r________ Diamete4� /.,. hQuF�Si ber -------/_________________ Rock Filled Yes No i❑ , <br /> Water Table Depth _---/�_ ---------------------------------Rock Size / --_--r �-----_---- <br /> --`----------- s------ Prop. Line r-------- <br /> ---------_---- <br /> Distance to nearest: Well _ -___�aj_ _Foundation '��___ i <br /> REPAIR/ADDITION(Prev. Sanitation Permit# •------------------------------------------- Date ----------------------------------1 <br /> SepticTank (Specify Requirements) -----------------------------------------------------------------------------------------------------------,.__...-----------•---•----------- <br /> DisposalField (Specify Requirements) --------------------------------------------------------------------- --------------------------------------------------------------- <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, 1 shall not employ any..,person. In such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed - Owner <br /> *� <br /> ' �d <br /> BY � ---------------- Title sB � <br /> ------------------------ <br /> ---------------- <br /> ---------- <br /> 0 <br /> --------'_.---- <br /> 0th �anowner) <br /> k FOR DEPARTMENT USE ONLY <br /> - <br /> APPLICATION ACCEPTED BY .__ 0------- -----$"---------------------------------- DATE --- ------1-°---- -----. <br /> BUILDING PERMIT ISSUED --- ---- -- C� - ----------------------- ---- --------DATE ------------------------------------------- <br /> ADDITIONALCOMMENTS ------------ ------------------- - -•------------------------------=-------- ---------------------------------------------------------------------------------- <br /> f <br /> __________________________________________________________________________________'_______.___________._______.__.__.________._______.___________.____________-_---_______-_____._________-_____._-___.__.- <br /> ___________________._._.___________________-_-_____ ______ __ ____-____ _______ _____ __ _ _-------- <br /> __ _ __ _ <br /> Final Inspection by: - = Date f a -� ------------------- <br /> ` SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M.' G ' <br />