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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> --------------------------------------------------------- Permit No. _7�__�0 3.. <br /> (Complete in Triplicate) <br /> ----__ 'This Permit,Expires 1 Year From Date Issued Date Issued -J9_,4 -7 <br /> l 4 fe--Oso - S'1j <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 /> , :T ` _ JPCENSUS TRACT __- <br /> JOB ADDRESS/LOCATION <br /> Owner's Name _.___l <br /> ----------, -5- ----------------------------------- ----------------- -I-V . <br /> __Phone __ __ _ <br /> Address �d-i- � ------------------------------------------------------ City -. .�Tt- U <br /> -&- <br /> Contractor's Name -- ----_•-�� -_- -� .ZZ �ent <br /> ---------------------------------License #�_��-�- _ Phone������+/__ � <br /> Installation will serve: Residence House f:] Commercial ❑Trailer Court"i❑ <br /> Motel ❑ Other -- ----------------------------------------- <br /> Number of,livin <br />� g units:-_. Number of bedrooms ___ml----Garbage Grinder_____________ Lot Size __/�_____411-zd;______ ------- <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 /> i <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet, <br /> k <br /> PACKAGE TREATMENT [ ] SEPTIC TANK f ] Size_______________________________________________ Liquid Depth ____--_______________,_____ � <br /> Capacity J -------- --- Type -------------------- Material---------------------- No. Compartments ------ •----•-- <br /> 1 <br /> Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ---------------------- <br /> LEACHING LINE [ ] No. of Lines ------------------------- Length of each line---------------------------- Total Length __________-__--_------_-_- <br /> 'D' Box --- -------- Type Filter Material --------------------Depth Filter Material ------------------------------ .............. <br /> Distance to nearest: Well ------------------------ Foundation ________________________ Property Line Y <br /> SEEPAGE PIT [ ] Depth ___ -i ------------- Diameter _______________ Number ---------------------------- Rock Filled Yes ❑ No 0 <br /> Water Table Depth ------------------------------------------------Rock Size -----------------'--------------- <br /> Distance to <br /> nearest: Well ----------------------------------------Foundation ------ Prop. Line --,--------------_.--- <br /> REPAIR/ADDITION(Prev. Sanitation, Permit# -------------------------------------------- Date _____________________________-____) <br /> i <br /> Septic Tank (Specify Requirements) --------- --------------------------------- -------------------------------------------- ----.. ---------------•---------- <br /> Disposal Field (Specify Requirements) _ +r-___r -,ry4`__-------�_---f-------_- -_-_-_____________________________ <br /> l �`G� ------------------------------------------------ <br /> ------------------------------------------------------------------------------ <br /> ------------------------------------------------- ------------------------ ----- <br /> ----------------------------- - - - - ----------------------------------------------------- -------- <br /> - ---------------------- <br /> (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 Son Joaquin Local Health District. Home owner or liven-„,-., <br /> sed agents signature certifies the following: <br /> "I certify that in the performance of the work for which this permit is issued, I shalt not employ any person in such manner <br /> as to become subject t ork Com �afion�Ila sof California.” <br /> Signed --- �� -------------------- Owner <br /> BY ---------- <br /> -------------------------------------------------- Title ----------------------------------- ------------------------------------ <br /> (If other than owner) I .� <br /> F DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY _.__ -____ -- <br /> -------------------------------------------------------------- DATE --- � - - - --��---�'A--------- <br /> BUILDINGPERMIT ISSUED --------------------------------------------------•-----------_-------------------------------------------DATE -------------------------------------------- <br /> ADDITIONAL COMMENTS -----------------------------------------------------•----------------------- : 1--- <br /> -------------------------- '----------------------------------------------------- <br /> ------•----------------------------- --------------------------------------------------------- ---------------------------- ----------------------------------------------------------- i <br /> ------------------------ <br /> - - - ----------------------------- ------- <br /> ------------------------------------- <br /> SAN <br /> ---- <br /> Final Inspection b ----.Date ------------- P- - - ----- --- ----------- ---------------- ---- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT I <br /> E. H. 9 1-'68 Rev. 5M <br />