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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PETIT <br /> -� 1 I f <br /> (Complete in Triplicate) ermit No. _.. <br /> Ed <br /> ---------=-- �---• ---------------------- I <br /> ---------------------------------------_----------------- This_PermitExpires 1 Year From Date Issued Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and instal} 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 -------------------------------- CENSUS TRACT --- <br /> Owners Name ---- � 1'. r =- = ` t= •`- :`------------------•----•- ••--------- - --------------Phone ------------------------------------ <br /> - 11; <br /> Address _ ��? f ----------------------------------------------- <br /> �:. ,-.f��> ;.� City - ------------------ <br /> -- - ----------- ---- <br /> Contractor's Name ---------------------------------------------------------=------•-License # Phone <br /> Installation will serve: Residence❑Apartment Pouse C❑ Commercial oTraiI&Court I] <br /> Motel ❑Other----=f! '" ..,__ <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❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam.❑ <br /> Hardpan ❑ Adobe.0 Fill Material ------------ If yes,type ---------------------------- <br /> I <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 T ] Size________________________________---------------- Liquid Depth <br /> Capacity --------------------- 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 Diameter ................ Number -----------------------____ Rock Filled Yes 0 No 0 <br /> Water Table Depth --------------------------------------- -------Rock Size -------------------------------- <br /> Distance to nearest: Well ----------------------------------------Foundation --------------- .... Prop. Line ---------------------- <br /> REPAIR/ADDITION(Prey. Sanitation Permit# -------------------------------------------- Date ---------------------------------_) <br /> Septic Tank (Specify Requirements) R - ..-_----�------------------------------------------- <br /> Disposal Field (Specify Requirements) ---- F.-_= = =F ^- tF-------, _ g----- � <br /> 1 X --------- -------------------------- --------------------------- <br /> ------------------------------------------------------------------------------------------------------------------------..-------------------=------------------------------------------ ---------.------ <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that t 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 Been- <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 �*_ _- =------------ L Owner <br /> By ! f. 6. € %r � k_ ------------------------------------------------------------------------ <br /> ;(if other than owner) Title <br /> 't <br /> FOR .DEPAATMENT USE ONLY <br /> APPLICATION ACCEPTED BY __ J `----- -------- ------------- <br /> I-=-•-,------------•------------•-•-----•-------•--•-------------------- - --- --•- �---- - • DATE -�`-------- <br /> BUILDING PERMIT ISSUED --- ------------------- -----------DATE <br /> ----------------------------------------------------------------------- ------- <br /> ADDITIONAL COMMENTS _____________ <br /> --------------------------- <br /> ----------------------------------__._L.----------------------------------------------------•----------------------_.-. <br /> ------ <br /> ---------------------------------------------------;T-------------------------------------------------------------------------------------------------------------------------------- <br /> -------------------------------- <br /> ----------------------------------------------------- <br /> ---------- - <br /> Final Inspection by1i =i= `-- --- ---- ----- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F. H. 9 ?-'68 Rev. 5M <br />