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If <br /> 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 /> 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 ---4;27 ---- -- ---------------------------CENSUS TRACT ---------------........... <br /> Owner's Name ._..._ <br /> ` l/�-�----,,--��- --------------------------- '---------------------------- ----------Phone ------------------------------------ <br /> Address � ---- - -------------- Cit ' <br /> Contractor's Name --------------- -- ----- //LE License # d'.3 'L Phone . <br /> sQ e <br /> Installation will serve: Residence partment House❑ Commercial ❑Trailer Court i❑ <br /> Motel ❑Other - <br /> Number of living units:-___ ------ Number of bedrooms ---3----Garbage Grinder --------- Lot Size ___-__-__-__----------------------------- <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 /> (Pl'ot plan, showing size of lot, location of system in relation to wells, buildings, etc, must be placed on reverse side.) <br /> F <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] c i Size___--------------------- Liquid Depth N <br /> Q, <br /> Capacity -------------------- Type ------ ---`i'�,---- Material---------_------------ No. Compartments <br /> - ---------------------- <br /> Distance to nearest: Well .---_--_ - <br /> - ---------Foundation -----------------------Prop. Line ---------------------- <br /> LEACHING LINE [ ] No. of Lines ------------------------ Length of eacliNl.ine---_---------- Total Length --_--_-_-----_-_-----_----_ A <br /> 'D' Box ------------ Type Filter Material -------------_Depth Filter Material --_-_-_--___-____ <br /> Distance to nearest: Well ------------------------ Foundation't:-_-__.-___.-------------- Property Line ------------•-----...... <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number --------------- Rock Filled Yes ❑ No i❑ <br /> Water Table Depth _____________ -------- �- -- _.______Rack Size _I�___"f--------------------- <br /> Distance <br /> ___________.__ .Distance to nearest: Well -----------------f----------------------Foundation s._-------__--_- Prop. Line -.-------.____._---_ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ------------------------ --------------------Date -----------------------------------I <br /> Septic Tank (Specify Requirements) __ _________________________ __. _ __ i <br /> Disposal Field (Specify Requirements) - <br /> SO <br /> -------------------------------------------------------------------------- - -------------------- �"`-" ---------------------------------------------------j---------------------------- <br /> (Draw existin 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 /> r <br /> Signed ----------------------------------- - -----' ---- 7 ------------=Owner �...�*� -----� — - ., <br /> BY -------- ----_--------- Title - -!'#J`±.. <br /> (If other than owner) <br /> 'Tl ' <br /> FOR DEPARTMENT USE ONLY I <br /> APPLICATION ACCEPTED BY ---- ------ -- -------------------------------------------------------------------------------- DATE ---� /f-_7_Z-------------------- ° <br /> BUILDINGPERMIT ISSUED ------------------------------------------------------------------------------------------ -------DATE - ----------------------------------------- ` <br /> ADDITIONAL COMMENTS . - <br /> ----------------p Y _ection----------------- -------- ------ ------- --------------- --------------------------------------------------------------------------------------------------------------- <br /> b --------------------------------------------------------------------------- <br /> ---- - ----- --- <br /> Final Ins _ Date ------_ <br /> __ <br /> -------------------------------------------- --__� ---r-7----- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />