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N/- 56 7 <br /> FOR OFFICE USE: r A r7,Y-/057 <br /> APPLICATION FOR SANITATION PERMIT �- <br /> ---------------------------------------------- <br /> (Complete in Triplicate) <br /> ---------- ----- D /7-7y <br /> --- <br /> ---------___________--_-_------ This Permit Expires 1 Year From Date Issued Date Issued L-_.-!_________-. <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 ----------------------------------------CENSUS TRACT - -------------- <br /> i d <br /> Owner's Name - --- ----- ----- ------ - ----- ------------------------------------------- -----------Phone <br /> Address ----- , d - '� -- ------ ------- --------------------- -- City -- 4---------------------------------------------•---- ........... <br /> Contractor's Namelllv^-'`------------------------------------------------------------------------License # ------------------------ Phone ------------------._..---_-- <br /> Installation will serve: Residence ❑ ApartX__ <br /> House,C7 Commercial :❑Trailer Court <br /> lMote ] te ----- ' '-.--.---- <br /> Number of living units_____________ Number of bedrooms ------------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 /> -. .� <br /> Ha_rdppri❑ Adobe ❑_ FillMaterial-------------- 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 /> i PACKAGE TREATMENT { ] SEPTIC TANK h] Size___3_#----------------------------------------- Liquid Depth -'�-L'___..____.._,_.__ L,�, <br /> Capacity 94!9---------- Type _ __ Material_4ttY a-----__-_ No. Compartments _ ________________ Q <br /> Distance to nearest: Well _______________________Foundation _.3_E!¢--------------- Prop. Line :c___________.___._ <br /> LEACHING LINE No. of tines I-------------------- Length of each line----9a--______----__ Total Length __!'o-------..-....... <br /> .. <br /> 'D' Box' ----- Type Filter Material A-&---------Depth Filter Material -1� <br /> Distance to nearest: Well 1_#!P_------------- Foundation _ ._ _--- <br /> ----------------- Property Line ............... � <br /> SEEPAGE PIT .[ ] Depth -------------------- Diameter ---------------- Number ------ --------------------- Rock Filled Yes '❑ No iC1 <br /> Water Table Depth ---- ----------------------------------=--------Rock Size ------------------------- --•--- <br /> i Distance to nearest: Well ----------------------------------------Foundation -----------.-------. Prop. Line ---------------------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ---------.........................) <br /> SepticTank (Specify Requirements) -------- --------------------------------------------------------------------•--------------------------------.----------------------------"All <br /> Disposal Field (Specify Requirements) ------------ - <br /> ----------------------------------------- ----------------------------------. <br /> - ------------------- ----------- -- - <br /> -. <br /> I (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 /> ---------- - - <br /> By --------- - _-_ �� ' Title -- ----- ---- <br /> - ------------------------------------------------------- <br /> (lf other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY --- ----------------------------- ------- DATE � ! ���'-----------__ <br /> BUILDING PERMIT ISSUED ----------------------------- --DATE -------------.--.----._.-------_ <br /> ADDITIONALCOMMENTS ---------------------------------------------------------------------------------------------------------------------------------- --------------------------- <br /> --------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------ <br /> ------------------------------------------------------------------------------------------- ---------------------- ------------------------- <br /> - ` <br /> -- --- -------------=------- <br /> Final Inspection by: -- - Dat -- ------------------- ------------------------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />