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FOR OFFICE USE: ;l <br /> ;I APPLICATION FOR SANITATION PERMIT <br /> ----------- -- --- ------------------------------ °, <br /> (Complete in Triplicate) Permit No: -.--- -: � <br /> This Permit Expires ] 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 t <br /> described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> --� _�JO$ ADDRESS/LOCA ON .-' - CENSUS TRACT <br /> Owner's Nameg - a------ -- ---------- ---------------------------------------- -------Phone ------------------------------------ <br /> Address - -- Z -', -------/-v'------ -------- City <br /> ! �Contractor's Name _ License # 1- .ca -. - Phone <br /> Installation will serve:' " Residence Apartment House❑ Commercial ❑Trailer Court ;❑ <br /> Motel ❑ Other ----------------=---------- <br /> Number of living units:-.--- ---. Number of bedrooms -.1----.-Garbage Grinder.--.-t_----- Lot Size ---_4il.e.e�•-+r ---.------ - <br /> Water Supply: Public System'and name --------------------------------•------------------------------------------------------------------------------Private <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt.0 Clay ❑ Peat ❑ Sandy Loam K Clay Loam ❑ <br /> I! <br /> Hardpan ❑ Adobe-❑ Fill Material ------------ If yes, type ---------------------------- <br /> (Plot <br /> ---------------__-. --(Plot plan, showing size of.Ilot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> 1ito\, <br /> NEW INSTALLATION: (No'septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT I III SEPTICTANK.I ] Size------------------------------------------------ Liquid Depth -------------------------- <br /> Cap acity <br /> ---------------------.---Capacity -------------------- Type -------------------- Material---------------------- No. Compartments ------•----------= <br /> !1 k <br /> Distance to nearest: Well ------------- -----------._-------Foundation _.-------------------- Prop. Line ---------- _.---.- <br /> LEACHING LINE [ ] No.11 of Lines ------------- Length of each line---------------------------- Total Length ------ ---------------------- <br /> -D' Box ------------ Type Filter Material -----'--------------Depth- Filter Material --------------------------------_---------- <br /> 0 <br /> Distance to nearest: Well ---------------- --- Foundation ------------------------ Property Line -----------.-----------. <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number ----..----.- ------ Rock Filled Yes ] No 0 <br /> Water Table Depth ------------------------------------------------Rock Size - ---------------------------- <br /> il ' <br /> Distance to nearest: Well ------------------------------- ------Foundation -------------------- Prop. Line ---..---__-.........-- <br /> i <br /> REPAIR/ADDITION(Prev. Sanitation Permit# --- ??- —------------------------- Date ------------------..--------------) <br /> Septic Tank (Specify Requirements) ------------------------------------------ -------------------------------•----------------------= <br /> a - <br /> Dis sal Fi Id (Specify Requirements) ----------- , • ------------------------ = <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 � �i -- Owner - <br /> By ------ '.es/,----- - --------------------- Title <br /> (if other than owner) <br /> " FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -- - -- ---- DATE 3 .-= ------------------ ------- <br /> ------------------ <br /> PERMITISSUED -9-------------------------------------------------------------------- -- ----------------=--------------DATE -------------•----------------------------- :. <br /> ADDITIONALCOMMENTS _1;---------------- --------------------------------------------------------------------------------------------------------------=-------------- ------------ <br /> --------------------------------------------------------- - ----------- <br /> ------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------- -- - ------------ <br /> ---------------------------------- -- - - ------- <br /> - -------- - <br /> Final Inspection by: ------------------- - ---------------------- --------------- -- - -------- Date �'"s ..6 --- - -- - ------------- h <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M !, <br /> JI. J <br />