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',FOR OFFICE USE: 1I -) J r/ (-,,0 t K-C " U e- I - U /--Uv <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) <br /> Permit No. <br /> This Permit Expires 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 install the work herein <br /> described. This application��iss-made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATI N .!----- �'----- -�c� �� ' l� -------- '-n,-S CENSUS TRACT _______________________ <br /> lP- - .------ <br /> Owner's Name �-� Cit Phone ... <br /> ---------- -------------------------- <br /> Address ,�ceM -' '{� Y ------ ` y �' <br /> Contractor's Name e T- ---------------------------------------License # Phone .............................. <br /> Installation will serve: Residence EnApartment House❑ Commercial:❑Trailer Court 0 <br /> Motel ❑Other ---- _/ -------------------- <br /> Number of living units:-----/_.___ Number of bedrooms ____`i'_- 'Garbage Grinder ------------ Lot Size _____________________ ................ , <br /> Water Supply: Public System and name --------------------------•----•--------- --------------------------•----------------------------------------Private <br /> Character of soil to a depth of 3 feet: Sand❑ Silt F] Clay F] Peat❑ Sandy Loam ❑ Clay Loam <br /> Hardpan Adobe ❑ Fill Material ------------ If yes,type ____________________________ <br /> r <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� ll" Liquid Depth 5/-�_ <br /> 7 Size_ _ __��_ <br /> �j '� `�� <br /> Capacity -__ Type_ Material__ - No. Compartments _ __-_---_--_.- <br /> Distance to nearest: Wello______.._____.•_____Foundation -----I_G2___`_______ Prop. Line -__s_-_--•______ <br /> LEACHING LINE [# No. of Lines _ ------------ Length of each line.......-6_0_._------------ Total Length <br /> 'D' Box .0 _ Type Filter Material -----4,9_?.....Depth Filter Material ----f.1r__________________ _ ............... <br /> Distance to nearest: Well -------!w?........... Foundation --------L_c?< ______ Property Line -S'_ <br /> SEEPAGE PIT [ Depth __�S�_____•__ Diameter __ _~__ Number ..-____ .__�_ ____ Rock Filled Yes Er--' No i❑ <br /> Water Table Depth -------------------------5�----------------Rock Size <br /> Distance to nearest: Well ------------1C,_0._`------------------Foundation ------1-0 Prop. Line ................ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date -_______-_-_____-_--_-__-_-•--____) <br /> SepticTank (Specify Requirements) ---------------------------------------------------------------------------------•----------------------------.,.-------------------------- <br /> DisposalField (Specify Requirements) -----•--------------------------------•---------------------------------------------------------------------------------------------- <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, 1 shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed .------- ----------------------- n Owner(frill/- <br /> -1 , o---C�� Title --1----- ------------------------------------- <br /> BY ----------_---------- <br /> -------- -- - <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -/,/,?--- - - j ----_---------------- ---------_---------- -------- DATE ---------------- <br /> BUILDINGPERMIT ISSUED ------------------------------------------------------------------------------- ----------- -------DATE ------------------------------------------- <br /> ADDITIONALCOMMENTS -------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> --------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------- ------------------------------ <br /> ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -- ----- <br /> _____.__._-r _ _ _ _ _ <br /> ____________________________________ ____ _ ._____._._ <br /> Tal Inspection by: � Date <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 9 1-'68 Rev. 5M <br />