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FQIt QFFLCE USE: APPLICATION FOR SANITATION PERMIT <br /> Permit No."9- <br /> --------------------------------------------------------- (Complete in Triplicate) <br /> This Permit Expires 1 Year From Date Issued <br /> Date Issued _ -.--1__--75? <br /> --------------------------- _ <br /> ----------- ---------------. <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 -------�ClLt��- _l f f l.1{EfE �f�� ------------ ----------------------- -----CENSUS TRACT -- - --------------- <br /> Owner's Name ---------------Phone ---AIMS 1"-----------•-------- <br /> C r�- � : <br /> Address ------------------------------------------------- --------------------------------------- City ------------ <br /> Contractor's Name --------------------- -------------------- -----------------.License # ---------:-------------- Phone -------------------------- <br /> Installation will serve. Residence ❑Apartment House❑ Commercial ❑Trailer Court ',❑ <br /> j Motel ❑ Other ---- --------------- <br /> Number of living units: ---- Number of bedrooms --1------Garbage Grinder PO--.- Lot Size ----- ---------A------------------------- <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 D <br /> Hardpan ❑ Adobe A Fill Material ------------ If yes,type ---------------------------- <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 /> � r <br /> PACKAGE TREATMENT { ] SEPTIC TANK'[ Size----------��*�-- --- --'`` -•----------- Liquid Depth --- -- -------------- <br /> Capacity -j0 ------- Type ---- MaterialNo. Compartments ---- __.--------- <br /> .� f <br /> Distance to nearest. Well -----------q __________________Foundation .-_-�p-___________ Prop. Line ___ ...,____-- <br /> LEACHING LINE [ ] No. of Lines ------a-------------- Length of each line--------50-------------- Total Length P � <br /> 'D' Box ---- -- Type Filter Material - :----.Depth Filter Material ---- -------------------------------- <br /> Distance to nearest: Well ---W- .--------- Foundation ---- _`�_ ------ Property Line ----------------- -- p <br /> SEEPAGE PIT j ] Depth -----------__--__- Diameter ---------------- Number -----------.__-__-.-- -- Rock Filled Yes (] No C] �`�'`1 <br /> WaterTable Depth ------------------------------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ------------.......... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ----------------------------- ------ ------ Date --------------------------.-------) <br /> SepticTank (Specify Requirements) -------- ------------------------------------------------------------------------- ---------------------------------------•-----------_-- <br /> DisposalField {Specify Requirements) ------------------------------------------------------------------------------------------------------- ----------------------------- <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 f <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 '/y <br /> - -------------- Title <br /> (If other than owner) ��,✓ <br /> FOR DEPARTMENT YS ONLY <br /> APPLICATION ACCEPTED BY ---------- ---------------------------------- -------- ---------, DATE ... ---------------------------- <br /> ------------------------------------------- <br /> BUILDING PERMIT ISSUED ----------------------------------------------- -- --------- --------------------DATE <br /> ADDITIONALCOMMENTS ------ -------------------------------------------------------------------------------------------------------------- --------------------- ........ ------ <br /> ------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------- ---- -- -------- <br /> } - - -------- <br /> Final Inspection b - -----------Date -----1-'- -fD-- -- -- ----------- <br /> p y: ----------------------------:---- ------------------------------------------------ ------ , <br /> SAN JOAQUIN LOCAL HEALTH TRICT <br /> E. H. 9 1-'68 Rev. 5M <br />