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s <br /> FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> - ---------------------- <br /> (Complete in Triplicate) Permit No. <br /> --------------------------------------------------------- This Permit Expires ] Year From Date Issues! 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 .- b---- ---�_tw 1 '__-\ C --------------------- -- ------CENSUS TRACT _-5 ---------___-- <br /> Owner's Name ,1 ------------------------- --------------------------------------------- ------------------Phone ------------ <br /> AddressSM -----•------------------------------------- Cit <br /> y -----�11 �2 ---------------------------------------------------- <br /> Contractor's Name ---stxr— =-------------------------------------- -------------------------License # ------ -.--------------- Phone ------------------------ <br /> r - <br /> Installation will serve: ResidenceKApartment House❑ Commercial❑Trailer Court ;❑ <br /> Motel ❑Other <br /> Number of living units:---- ------ Number of bedrooms - _--_Garbage Grinder �kQ____ Lot Size - ---�C <br /> -------------- <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 /> (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 [ SEP' <br /> ItC TANK f ] Size------------------------------------------------ Liquid Depth--------------------------- <br /> Capacity -1?,oa.Ghl Type CfWT__ Material No. Compartments -- --_ - <br /> Distance to nearest: Well -s ---------------- -- r ,�,/ f <br /> LEACHING LINE No. of Lines ��11 <br /> - ------.Foundation _.--�-------------- Prop. Line ---/��---••---••--- <br /> �Q oma- Length of each <br /> ?_line------� -------- Total Length --_t�Q---------------- <br /> ' D' Box __ __ Type Filter Material �1� !_�Srr�Depth Filter Material -_-___. -- --------------------------------- <br /> Distance <br /> ��} <br /> lg <br /> Distance to nearest: Well _-r71_45--------------- Foundation --ICJ---------------- Property Line <br /> SEEPAGE PIT [ ] Depth --- -------------.-- Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No i❑ <br /> E <br /> r Water Table Depth ------------------------------------------------Rock Size ------ ------------------------- <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ----------_---------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ---------------------------------_--------- Date ----------------------------------) <br /> SepticTank (Specify Requirements) --------------------------------------------------------------------------------------------------------------•----------------------------- <br /> Disposal Field (Specify Requirements) --------------------------------- --------------------------------------------------------------------------------------------------- <br /> ------------------------------------------------ -- -------------------------------- - <br /> __ <br /> ! {Draw existing and required addition on reverse side) <br /> F 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 beca subject to Wrkman's Co tion laws of California." <br /> Signed Ef/ ----------------------------------- Owner <br /> By - ----------------- ------------------------------------- ----------------------- Title ---- - --- <br /> (If other than owner) <br /> I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY I - DATE <br /> k <br /> BUILDING PERMIT ISSUED - DATE ------------------------------------------- <br /> ADDITIONALCOMMENTS - _ C ----------------------------------------------------- --------------------------------------------------- <br /> ------------------------------------------------------------------------ <br /> ------------------ --------------------------------------------------------------------------------------- --------------------------------------------------•---- -------------- - <br /> --- --- ---- - - ---- <br /> -- ----------------------------------------------------------------------=--------------------------- ----------- -Final Inspection by- --- ---------- - - ------------------------ -- -- ------------------- -------.Date ---��.`• ----------------------- <br /> SAJOAQUIN LOCAL HEALTH DISTRICT <br />[. <br /> E. H. 9 T-'68 Rev. 5M <br />