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1 <br /> FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT �• <br /> (Complete in Triplicate) <br /> Permit No. .. %./___ ------__. <br /> . --.._............ M <br /> .. This Permit Expires 1 Year From Date Issued Date Issued �. ..v_._.W <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/. ./ `- ' .CENSUS TRACT .......................... <br /> Owner's Name ... -•------•. . . ...................Phone - t <br /> lAddress ...... .................. <br /> d _ <br /> tc �:.1. ?- t ..,� City ..... --•--•... <br /> Contractor's Name .., r: ........... ....................License # - --- ----- Phone ----- ----------- <br /> Installation will serve: Residence M Apartment House-[] Commercial ❑Trailer Court ;❑ <br /> Motel ❑Other........... ............... __-----...... <br /> Number of living units:... ._.. . Number of bedrooms .3.......Garbage Grinder ..... ------ Lot Size 3 r- <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 Fill Material ----- If yes,type------- ------------_------ <br /> L n <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 sewgr is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANKPJ Size_J._.__. __ .1__......__._...._.... Liquid Depth ._...___________________ \� <br /> Capacity <br /> ------ ------ MatenaLwt"-,."-:.......--- No. Compartments ------------_--------- <br /> Distance to nearest. Well ._.____---_-_-.-.--.-:Foundation .._�!... ....._--_- Prop. Line .. ................. <br /> LEACHING LINE [ ] No. of Lines --.--'7............... Length of each line_..1, a:�.)-----------.- .. Total Length ___ _ <br /> D' Box4Zt'�-L_�Type Filter Material ,,'_ '........Depth Filter Material ___ ________________-_---_-_-_._.--•_._ <br /> Distance to nearest: Well --. ?-------------- Foundation ._%..±?._ ----------.- Property Line :-<--___________________ <br /> SEEPAGE PIT [ ) Depth -------------------- Diameter ................ Number ----------.----------- ---- Rock Filled Yes ❑ No i❑ <br /> Water Table Depth ---------------- ------ ------ ----------------Rock Size ------ ._---------------___ <br /> Distance to nearest: Well -------.._...-.------------------------Foundation Prop. Line ---..__._----.--_.-_- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ............-------.-.-.-----__--) <br /> Septic Tank (Specify Requirements) <br /> Disposal Field (Specify Requirements) ----------- ------------------------------ --- - -------- --------------------------------------- <br /> ... -- ... -- ------------------------------------------------- ...................... --------- -------------------------------- ---------------_--------._.-... <br /> -----------------------------------------------­---------- --------------------------------------=--. ------------------------- ...........-----------------------------_------ <br /> (Draw existing and required addition on reverse side) <br /> 1 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 become subject to Workman's Compensation laws of California." <br /> ,"$ l <br /> Signed ?CG:r :v5rr!==----------------------•---------------- ------------- Owner <br /> By ......... ........................................... ----------------------------- Title ..... .- ... .. .......------------- ---....------- --------- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> _ f <br /> APPLICATION ACCEPTED BY ! ':_ - .�..t:f- '%. - - ----- ------------ . .. - DATE - <br /> BUILDINGPERMIT ISSUED -•-------------•----•----------- - -------—------- -- - -----....DATE ------------•----- -_------------------- <br /> Oy � ._. .. t ------------ <br /> ADDITIONAL CM - f -- <br /> _.- .. --_----- _-- --- -------------------- ----------------------------- --- <br /> ------------------- - '' --.......0-------- <br /> ---- <br /> Date -1 ---------- <br /> Final Inspection by: z'?'_� i,,,.{r -•------------- ------------------------------------------------I--- _ �,. <br /> ----------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />