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v <br /> FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> z� `\`�" Permit No. --/!SS-. <br /> -------------- - <br /> (Complete in Triplicate) <br /> ---------------------=----------------- <br /> <� � Date Issued <br /> ----------------------------------------------------_--_ This Pe"rmit Expires 1 Year From Date Issued <br /> Application is heVeSy' ma &-t tFie San JOc�q�uiri CocaZ`Healtfi DisfiY'ict `for:a"pe,rir+it to construct and install the work he`einr <br /> describeda„This application is made in comPVM_ e•w'th Cq�tyOrdinaarr"e Nc 5491and existing Rules and Regulations: i <br /> y <br /> JOB ADDRESS/LOCATION”_f_ -- -- -- - - - - --------------------"- ------------CENSUS TRACT ----------------- -- -- <br /> Owner's Name �� �- � *� ------------------------------ ------ ------Phone------- --------------------A <br /> Xr� <br /> Address = City ------------------ ------------- ;-- <br /> Contractor's Name _-__ �"�" r censer# Phone / _.: `- - <br /> Installation will serve: f ' - Residence �Qpartment House,❑ Commercial:❑Trailer Court ',❑ <br /> Motel-FJ'Other -------------------------------------- may► <br /> Number of living units._-/-.-- Number of bedrooms _- _--__Garbage Grinder _ G Lot Size / �C� _� �----------------- <br /> Water Supply: Public System and name . x_._ _ !" - ---------- ---------------•---------Private ❑ <br /> Character of soil to a de th of 3 feet: Sand` Silt❑ Clay ❑ Peat;❑ �Saridy Loam ❑ Clay Loam ❑ l <br /> Hardpan ❑� Adobe Fill Material`.----- if yes, type _-___.____..______________ i <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 [ ] •"SEPTIVTANK k,l ize __ / _ ____________________ Liquid Dep;hll ____._--_____-_.- <br /> _ ,� , <br /> #Capacity�.e �____------ Types-° - _ ------ Material_ -------- No. Compartments - =-----------•-.-.-- <br /> ` Distance to nearest:-Well -_-_,____ ---__ _ `' Foundation _.,. ------------- Prop. Line --_-_-----_ <br /> LEACHING LINE X1 �No. of Lines '-- ------------------- Length of each linaint _ .�__. Total Length .00____---------------- <br /> 4' <br /> _______________ <br /> s -_ <br /> 'D' Box q--- Type Filter Material l� �__Depth Filter Material ________A-------------------------- <br /> `� ' et ----_ Foundation ----__ Property Line. -- '____- <br /> �„� <br /> Distance to nearest: Well _____�_ 6J �� p ty • - <br /> SEEPAGE PIT ] Depth s---r?A.$------ Diameters$ - Numbe�--------------------------- Rock Filled Yes No is <br /> Water Table Depth ----------IKO--------- ” -- Rock Size r---------- <br /> Distance`fo nearest: Well'-----=°�•___=� -----------------Foundation --,e... ......... Prop.,Line ___/ ........... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- <br /> l ` Date -----------------'----. ------- <br /> -nen Tank (Specify Requiremi I <br /> ' <br /> Disposal Field (Specify Requirements) ------------------•-- ------------- -------------'--------------------------------- <br /> 1__`1All - ---- 1 7'Jy ------" 4l�-------- <br /> k <br /> (Dnw existi'hg and required addition on reverspide) - <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 Ill Health District. Home owner or licen- <br /> sed agents signature certifies the following: l r� <br /> "I certify that in the performance of the work for which this permit is issued, 1 s�all'not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed ----------------------- --- -- ------------ ----- - ----- ------------------------------ Owner <br /> -------- Title ...GFS ---------------- ------------ <br /> - <br /> (if of an owner) ' <br /> FOR DEPARTMENT USE ONLY .� <br /> APPLICATION ACCEPTED BY - ---------- DATE �� - -- ---------- <br /> 6? <br /> BUILDING PERMIT ISSUED - ---------- _ ;------------------------------------------------------------------------ DATE <br /> ADDITIONAL COMMENTS ----------- --------------------------------------- --------------- <br /> ------- - ----------------------------------------------------------------=--------------------------- <br /> --------------- <br /> ---------------------- -- ----------- - ------ - ----- - ----------- <br /> -- ------------------ ----------------------------------------------------------------------------- Y <br /> Final Inspection by- ------------- - - -----------------------------------i---------------------------------Date --- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> JIiW`� <br /> E. H- 9 1-'68 Rev. 5M <br />