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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> Permit No. ....��0-. <br /> ---------------------- ----- ---------------- (Complete in Triplicpte) <br /> ----------------- ------------------ --------------------- Date Issued -Z—:4 <br /> This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a per to construct and install the work herein <br /> described. This application is made in compliance with County Ord : <br /> diinaance No. 549 and existing Rules and Regulations <br /> JOB ADDRESS/LO I N .. G-1�0---- - --�?_e------- -----CENSUS TRACT ------------------------- <br /> -._ _ . <br /> Owner's Name ._ - -- - ----�'---------'----------------------- ---- --------- -------------Phone ------------------------------------ <br /> - <br /> ---------- ------------------ •---- <br /> -- - ---------------- - ----------- - <br /> -r LlAddress -- ------- --- ._City --�- �Contractor's Name ... <br /> -------------------- <br /> Installation will serve: Residence Apartment House❑ Commercial :❑Trailer Court ;❑ <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 El Clay E] Peat El Sandy Loam (Clay Loam ❑ <br /> 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 { ] SEPTIC TANK'{ Size----------------------------------- ----- Liquid Depth -------------------------- <br /> Capacity -------------------- Type ---------------•---- Material-------------- ------ No. Compartments ------------_------- O <br /> Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line -----------------.---- <br /> LEACHING LINE [ ] No. of Lines ------------------------ Length of each line-------_.------------------ Total Length ----__-_-----.--------_-- Ln <br /> 'D' Box ------------ Type Filter Material --------------------Depth Filter Material ------------------------------------- ------ <br /> Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line. --------------_.--._..._ <br /> SEEPAGE PIT Depth . Diameter ---------- ------ Number ---------------------------- Rock Filled Yes ❑ No i❑ G <br /> WaterTable Depth ---------------=--------------------------------Rock Size ------------------------• •---- <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line --------------------.- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ---------------_---------------------------- Date ----------------------------------) <br /> Septic Tank (Specify Requirements) -------- --------- -----------------------11�------------ ------------- ------ <br /> �.. <br /> (Disposal Field (Specify Requirements) --- ----_ . -------------- <br /> 'A <br /> :�y <br /> s �--� <br /> - ---- --------- <br /> -. A -- �---- ._''_ ` _- -------------------------------------------------------------------- <br /> ------------------------------------------------ - <br /> ----------------------------------------------------------------------------------------------------------------------- <br /> (Draw existing and required addition on reverse side) <br /> i 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 /> R as to become subject to Workman's Co nsation laws of California." <br /> Signed -------- ------------------------ ---- --------- Owner <br /> BY Tit -- . . --- . .. .................................... <br /> ------ ---------- -------- --- <br /> ------------------- ---- --------- -- ----- -- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> DATE .f_'..`�r�'�Z/– -----=-- ---- <br /> APPLICATION ACCEPTED BY -.-.. .�__-- ?!I-__-------- --. <br /> BUILDING PERMIT ISSUED -------------------------------------------- - <br /> --------- --------------------- --------------DATE ------------- -----------------------'------ <br /> ADDITIONAL COMMENTS ------------- ----- ----------------------------------- -------------- <br /> -------------------------------------------------------------------------- <br /> ----------------------------------------------------- -------------------------------------------------------- -------------------------------- <br /> - <br /> ------ -- <br /> ------ --- f� j <br /> 0 <br /> Final Inspection by: /!1f� d---------- --------- ----------------------------------- - - ------------Date/ ' L�' 7F _ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> k �. H. 9 1-'68 Rev. 5M 1 - <br />