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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ------------------------------------------ Permit No: <br /> (Complete in Triplicate) _-- <br /> This Permit Expires 1 Year From Date Issued Date Issued -------`----��•---• <br /> --- - ------------------------------------------ ------- <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 made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATI N ✓ - ��--�--- <br /> --------------------------CENSUS TRACT -S-Y-1---•-•--------- <br /> Owner's Name ---- --- <br /> } -------Phone ------------------•-•--------------- <br /> /�ir7 / -------i:' -. <br /> Address ---- - -'- - - - ---- -------. City -= -"- - -[-------------------------------------------------------- <br /> a <br /> -------------- ------------------•-----------------• <br /> e I- - --�- --------------- ----==--------License # -�JW`3_92---- Phone ------------------------------ <br /> Contractor's Name ------ ___ ___ ---- <br /> Installation will serve: Re idence 2r'A'partment House❑ Commercial ❑Trailer Court ;❑ <br /> Motel ❑Other ---------------------------------------- <br /> Number of living units:-----I----- Number of bedrooms ----:?��Garbage Grinder ------------ Lot Size ___________________________________________ <br /> Water Supply: 'Public System and name -------- ----------•---------------------- - --------------------------------------------•-- <br /> ______________Private I <br /> Character of soil to a depth of 3 feet: Sand'E] Silt❑ Gay ❑ Peat❑ Sandy Loam ❑ Clay Loam:[5" <br /> Hardpan ❑ Adobe ❑ Fill Material ------------ If yes, type ---------------------------- <br /> (Plot plan, showing size of lot, location of�system in relation to wells, buildings, etc. must bb placed on reverse side.) ' <br /> NEW INSTALLATION: (No septic tank or seepage spit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK'[.] Size------------------------------------------------ Liquid Depth ------------•-•----------- <br /> Capacity Type -------------------- Material---------------------- No. Compartments ------ --------•-a•--- <br /> 1 <br /> LAI <br /> E Distance to nearest: Well'.,;__-__�_r_ <br /> --- "--------------------Foundation -------------1-------- Prop. Line -------_-- _-------- <br /> LEACHING <br /> I <br /> LINE L ] No. of Lines ------------------------ Length•af each line---------------------------- Total Length ____--.____-_____-------.-__ <br /> I 'D' Box ---------- --Type-Fi[ter--Materia('--------------------Depth Filter Material --------------------•----------•-------=• ' �' i <br /> 6 y <br /> �• I Distance to nearest: Well. ---_--�----:,l------- Foundation ----------------------- Property Line ------------------------ <br /> 14J3. <br /> SEEPAGE PIT.` [ ] Depth -"Diameter__-__--Y______ Number� --"------- Rock Filled Yes ❑ Na !❑ <br /> Water Table Depth ----------------------------------------- Rock Size ----------------------- <br /> a I t <br /> £ 1 ,Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ---•----------.--:- <br /> b <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ------------------.---------------I <br /> Septic Tank (Specify Requirements) ----------------------------------------------- - -- _------------- ---------- ----------------------•--- `r <br /> ----------------- <br /> Disposal Field (Specify Requirements) ____ -r ------ <br /> - ''a 3` . <br /> Qr 3z��.• <br /> /�-°------- --- �' ----------- ---------- ----- -- --------------- --------------------- <br /> 'r <br /> ' ' --------------------------------------------------------------- <br /> ----------------------------------- -------------------------- -- - - - - <br /> I• (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 Ai <br /> County Oirdinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- 7 <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." j <br /> - <br /> OwnerSigned ----- <br /> --- - - = --------------- <br /> ---- ----------------------------------- - ---- y <br /> ! <br /> Title __cC'�itisit ----- <br /> (If other than owner) _ <br /> E FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -- ------------------------------------------------------ ------------ DATE _ _` <br /> BUILDING PERMIT ISSUED ------------=-----------= ----------DATE ------------- --------------- -------- <br /> ADDITIONALCOMMENTS -------•----------- ----------------------- ----------- ---- ------- <br /> ---------------------------------------------- <br /> FinalInspection by. rl --------------------------------------------------------------------------------------Date ----- - -- ----------- <br /> r SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E_ H. 9 1 '68 Rev. 5M. - <br />