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FOR OFFICE USE. APPLICATION FOR SANITATION PERMIT <br /> ------------ ----- - ----------------------------------- - � <br /> .. (Complete in Triplicate] Permit No. <br /> - -----=------------ -------------------- ----------- Date Issued -19---=1 G_�__.G <br /> _____ --- <br /> -------------- ------- ' This Permit Expires I Year From Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a per to construct and install the work herein <br /> described. This application is'rnade•in compliancelVith County rdin a No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATIO��-��/QQ'-- �--J-------- --- <-----------------------------CENSUS TRACTr ------------------.------- <br /> Owner's Name ------------G.: - ---- ----------------- - ------------- ---Phone��_`y__ � . <br /> Address _ p "' _ - ------ ----- ----------� . <br /> ---t City - <br /> Contractor's Name --------------- --- - -- -- =- -y -----.License # f1 ---- Phone' <br /> Installation will serve: Reside nce'�jLlApartrrient,Houi6`E) Commercial-❑Trailer Court '[] <br /> Motel ❑Other -------- - ------- <br /> Number of living units------!------ Number of bedrooms _Garb Gr - <br /> d Lot Size ----- - -- '-�-Z <br /> " <br /> Water Supply: Public System and name ----------------------------------------- ..... = ' Private 11 <br /> Character of soil to a depth of 3 feet:' Sand'❑ Silt❑ Clay F1 Peat❑ Sandy Loam ❑ Clay Loam 'EJ <br /> ,-Hardpan E] Adobe Fill Material �___--- If yes, type ____________________________ <br /> (Plot plan, showing size of lot, locdtion of system in relation jp 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 /> '. r <br /> PACKAGE TREATMENT [ ] SEPTIC TANK T ] Size---------------- ----------------- _ Liquid Depth ------------- <br /> ------------- <br /> t <br /> Capacity -------------------- Type -------------------- Material----------------------- No. Compartments --------- ------------ <br /> Distance <br /> ----------------•--- <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 f I Depth ____________________ Diameter -------- ------- Number ---------------------------- Rock Filled Yes ❑ No <br /> WaterTable Depth ------------------------------- ----------------Rock Size -------------------------------- <br /> Distance to nearest: Well -----------------------------------------Foundation -------------------- Prop. Line ------.---------__---- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ----------------- Date+-"`= '- -- Date ---_____.__._______---------_-.--) <br /> IX <br /> Septic Tank (Specify Requirements) ------------------ ----- ---- ---------------------- <br /> Disposal <br /> -------- �------- � <br /> - --- <br /> Disposal Field (Specify Requirements)- Z <br /> ---------------------------------------------------------------------------------------- <br /> j <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 become subject to Workman's Compensation laws of California." <br /> Signed ---- =---------------- ---------------------------------- Owner <br /> BY ---- - -- - -- -- --- { <br /> Title • - <br /> (If of r than owner) <br /> FOR DEPARTMENT USE' ONLY <br /> APPLICATION A C TED BY ____-______ _ _ <br /> -�- - --------- ----------------------------------------------- DATE -- �1�.. 7--•------------- --- <br /> BUILDINGPERMIT ISSUED --------------------------------------------------------------------------- -----------------------------DATE ------------------------------------------- <br /> ADDITIONALCOMMENTS ---------------------------------------- -----------------------•---------------------------------------------------------------- -------- - ---- <br /> ------------------------------------------------- <br /> -------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------- <br /> -- ------Date _ :------- --------------------------------------------------- --------------- ----------- <br /> Final Inspection b SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev, 5M <br />