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} <br /> FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate] Permit No. <br /> ------ ----------------------------------------------- r <br /> This Permit Expires 1 Year From Date Issued Data Issued <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 ._.___--- f -_j�� S ___.__ '___ -gA � ------------------ CENSUS TRACT ------S7'--_..___. <br /> Owner's Name ------ ---------------- IWA-, <br /> VM-�------------------------------------------------ -------------------Phone �_�_5 �86� <br /> - -- -- -------------- <br /> Address --- ---------------------------------------------- A--------------------------------------•--- City ---------------------------------------------------------------------------- <br /> Contractor's Name Cf - License # Phone <br /> Installation will serve: Residence r Apartment House,[] Commercial ❑Trailer Court 0 <br /> Motel ❑Other - ------------------------------------------ <br /> Number of living units_____________ Number of bedrooms ------------Garbage Grinder ------------ Lot Size .____________-______---__------.---.__-_____ <br /> 4 Water Supply: Public System and 'name -------------------------=-----------------------------------------------------------------------------------Private ❑ <br /> Character of soil to a depth of 3 feet. Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam .E] Clay Loam ❑ <br /> I Hardpan ❑ Adobe ❑ 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 /> PACKAGE TREATMENT f ] SEPTIC TANK'f ] Size------------------------------------------------ Liquid Depth _.__-___-._.._.._...- <br /> Capacity -------------------- Type -------------------- Material---- No. Compartments ------------------_-- J <br /> 3. .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 Lihe----------------- <br /> SEEPAGE PIT [ ] Depth Diameter ________________ Number ----------------..---------- Rock Filled Yes [] No 0 <br /> Water Table Depth -----------------------Rock Size -----------------------_--__---- <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ...................... <br /> 11 <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------..__/ -_________.__ Date __________________________________) <br /> Septic Tank (Specify Requirements) r <br /> Disposal Field (Specify Requirements) ---------------•--•--------- ------I ------ -- --------------------------------------------------------------------- <br /> i <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, 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 /> i <br /> BY - --- ---- --------------------------- Title ------------------------------------------------------ <br /> (Ifother than owner) <br /> FOR DEPARTMENX USE ONLY <br /> APPLICATION ACCEPTED BY ------------ ---- -------------------- ---------- -- - -- - ----------- DATE <br /> -121 -3 ------------------- <br /> BUILDING PERMIT ISSUED DATE <br /> ------------ ---------- ----------------------- - ------ <br /> ADDITIONALCOMMENTS -------------------------------------- ----- ------------------------------------------------------------ ------------------•,----- -----•---------------- <br /> ------- - -- -------------------------------------------------------------------- --------------- ------------------i--------------------------- ---------------•------------------------ ---------------- <br /> --------- ---- ------ --- --------I------------------------------------------------------------------------------------------------------------------------- -------------------------------------------- <br /> ' ---------------------------------------------------------------------------------------------------------------------- ----------- <br /> - ----------------------- <br /> Final Inspection b Date -- - -------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />