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FOR OFFICE USE: <br /> i <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) <br /> Permit No: <br /> This Permit Expires ] Year From Date Issued 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. 544 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION _-- $1 TRY�G -fin-------------------- �2flc,`r---- CENSUS TRACT 5 <br /> Owner's Name ----- --------- ---------------- ---------------------------------------------------_-•-------------------Phone <br /> Address - -------------------------- J�l----------------------------------------- City :Ta' i�cy----------------------------------------. -------------------- <br /> Contractor's Name ---------------------ft•3Wort,--------------------------- ----------------=--------License # ------- --------- ------- Phone ------------- ---------------- <br /> installation will serve: Residence ❑Apartment House❑ Commercial ❑Trailer Court ;❑ <br /> K, <br /> r <br /> Motel ❑ Other ---------------------------------------•--- i <br /> Number of living units------------- Number of bedrooms -------_--.Garbage Grinder ------------ Lot Size -------------------------------------------. <br /> Water Supply: Public System and name .--- ----------------- ------------------------------------------- ------------------------------------Private ❑ <br /> Character of soil to a depth of 3 feet. Sand'❑ Silt p Gay ❑ Peat❑ Sandy Loam ❑ 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, 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 J-------------- --- Type -------------------- Material------ --------------- No. Compartments -----------------:---- <br /> Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line <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 /> SEEPAGE PIT [ ] Depth -----I---.-- ---- Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No i❑ <br /> Water Table Depth ------------------------------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well ---------_---------------------- ----Foundation -------------------- Prop. Line ---------------------- " <br /> F <br /> REPAIR/ADDITION[Prev. Sanitationi.Permit# -------•--------------------------------- -- Date ------••---.•-----------------_-_-) <br /> I <br /> Septic Tank (Specify Requirements) ------------------ ------------------------------------------------------------------- --------------------------- <br /> 1 <br /> Disposal Field (Specify Requirements) ------- jg1jPtU--lie-----D ------- ------------------------------- <br /> ------------------------------------ ------------------------------ ------------------ <br /> E <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 becoubject to Workmgq's Compensation laws of California." <br /> Signed = dLf. s. 2..��f/� C--------------------------------- Owner <br /> By --- -------- -------------------------- -------------------- <br /> --------- Title -------------------- <br /> -------------------- <br /> ---------------------------------------- <br /> (If other than owner) i <br /> FOR DEPARTMENT LJ E PNLY, <br /> APPLICATION ACCEPTED BY --------- --- ----- --- p U <br /> - - - - ------. DATE ---- ----------------- <br /> BUILDING PERMIT ISSUED ---------- -- - --- -----------------DATE ------------ •--------------------- ------- <br /> ADDITIONALCOMMENTS =--------------------- - --- ------ ----------------------------------- --------------------------------=---------- ----- --------- <br /> k <br /> I--------------------------------------------- -Final Inspection by ----------------------- - - <br /> - --- - - - -- <br /> -------- <br /> SAN JOAQUIN LOCAL HEALTDIS- RICT <br /> E..H. 9 1-'68 Rev. 5M a <br />