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1 <br /> FOR OFFICE USE: r' <br /> APPLICATION FOR SANITATION PERMIT <br /> -- -------------------- -------�---------- --- Permit No. ----- ------- -- - -� , <br /> {Complete in Triplicate? <br /> This Permit Expires 1 Year From bate Issued Date Issued <br /> _ <br /> ------------- ----------------------------,----------- <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 Ordinance No. 549 and existing Rules and Regulations. <br /> JOB ADDRESS/LOCATIO�NJ . -,�_-5?1�;,-- � �"' . ..a W ��'----------------------CENSUS TRACT -------------------------- <br /> Owner's Name --------/1~.- -�/� -----------------------•--•---------------- --------------------------------------Phone --------------------------- ---•---- <br /> yy� <br /> Address ----- g�_.1 l- ----------------------•-------------------------------------------- City <br /> Contractor's Name -------- Pr• P_-.'�efv�-7,��-- ----------------- ------.License # ---------:-------------- Phone ------------------•---•------- <br /> Installation will serve: ResidenceX Apartment House°E] Commercial ❑Trailer Court :❑ <br /> Motel ❑Other -----------------------------------•-------- <br /> Number of living units:-J.--- Number of bedrooms _--'3-----Gaarrbage Grinder AW- Lot Size _1_c26;)X___ ----- <br /> Water Supply: Public System and name ---- 0_/f-------------------------------•----------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Gay ❑ Peat❑ Sandy Loam -❑ Clay Loam;j] <br /> Hardpan ❑ Adobe 9 Fill Material ------------ If yes, typel <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 [ I SEPTIC TANK [ I Size------------------------------------------------ Liquid Depth ------------------------- <br /> Capacity -------------------- Type -------------------- Material---------------------- No. Compartments -----------•-•.......... <br /> Distance to nearest: Well ------------------------------------Foundation ---------— --------- Prop. Line ---------. .. ,------ <br /> LEACHING LINE No, of Lines ------ --------------- Length of each linee----- -------0,--,.f Total Length __,/10.-� -__-._-_- <br /> ^�t;if 'D' Box -1 Type Filter Material f�CDepth Filter Material .-- ----------------.•-------.------ <br /> Distance to nearest: Well -____�--__-______ Foundation ____X-0---._______ Property Line -__ �-____...-.. <br /> SEEPAGE PIT rk Depth ----._._.__-___-- Diameter ________________ Number ---------------------------- Rock Filled Yes ❑ No .l❑ <br /> WaterTable Depth ------------------------------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ........-------------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------1 <br /> Septic Tank (Specify Requirements) ---------------- - - -------------- ------------ W_------------------ <br /> Disposal Field (Specify Requirements) -------� ------���----- f'--�s�'�� /---��' ­.,A- <br /> _ Z --------------- <br /> 7. � - ----to ---------------------------------------------------------------------------- ------------------------ <br /> ----------------------------------------------- --------------------------•-------------------------------------------------------------------------------------------------------------- <br /> (Draw existing and required addition on reverse side) <br /> f I hereby certify that I have prepared this application and that the work will be done in accordance with Son 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 ------------------- ---- <br /> ------------- ----------------------------------- Owner <br /> BY ---------------------------- ----------- --------------------------- Title ------6 .-'--------------------------------------- <br /> (if o than owner) <br /> F <br /> !OR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY - - .e_-- --------------------------------------------------------------------------. DATE --/�-I------•-----------------•- <br /> BUILDING PERMIT ISSUED -- ------------------------------------------------ -- ---DATE ------------------------------•------------ <br /> - --------------------------------------------------- <br /> ADDITIONAL COMMENTS -- --- ---- --- --------- <br /> ------------- ------------------------------------------------------------------------------------­1- <br /> •- <br /> --- <br /> --------------------------�Y�e <br /> -------- ------------- ---- -------------- ---------------------------------------------------------------------------------------- <br /> -------------------------- ---- -- --- --- ------------------------------------------------------------------------- ----- -- <br /> - <br /> Date --------7 ---------- <br /> Final Inspection - ----------SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />