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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT / <br /> --------------------------------------------------------- <br /> (Complete in Triplicate] Permit No. <br /> ---------=----------------------------------------------- <br /> This Permit Expires ] Year From Date Issued /� <br /> Date Issued -3`�2-_-�/ <br /> ------------_------_ _ _ <br /> -------- ---------_--- --------- <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 /> V1 - <br /> SqJ <br /> JOB ADDRESS/LOCATI N .- ----_70- --- _ ,� --_. <br /> - _` =' CENSUS-TRACT <br /> Owner's Name . --------------------------------- -------------------Phone ------------------------------------ <br /> Address -------- - G `f City =• " " <br /> I r O <br /> Contractor's Name --- -- - ----- _ -.License # 1 Y Phone <br /> Installation will serve: Residence ❑Apartment House❑ Commercial.:E]Trailer Court ;❑ <br /> Motel ❑ Other ---------------�--------- <br /> Number of living units----------I--. Number of bedrooms __-?_____-Garbage Grinder ------------ Lot Size -------------------------------------------- <br /> h Water Supply: Public System and name ------------------------------- -= --------------------------------------- ---------------------.-------------Private ❑ <br /> Character of soil-to-a-depth of3,feet: -SandClay -❑, Peat,❑�+Sandy_iLoam.[ Clay Loam:❑ <br /> Hardpan � ; ,Adobe ❑ Fill Material—___-:- If yes, type ---------------------------- <br /> (Plot <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,J <br /> PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] Size--------------------------------- Liquid Depth -------------------------- <br /> Capacity ------------------ Type ------------------- Material---------------------- No. Compartments Y------•--•---------- <br />'E Distance to nearest: Welt ------------------------------------Foundation -------_-.------------ Prop. Line ---------- ------ <br /> LEACHING LINE [ ] No. of lines --------------------- Length of each line----------------- - ------ Total Length ----_-------------_-__-__ <br /> 'D' Box .-I--------- Type Filter Material --------------------Depth Filter Material ---------------------------------------.---- <br /> i <br /> Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line ------------------------ <br /> SEEPAGE PIT [ ) Depth ----'--------------- Diameter ---------------- Number ----- ---------------------- Rock Filled Yes ❑ No <br /> WaterTable Depth ------- ----------------------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line --------..---_-_------ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -•------------------------------------------ Date ---------------------------------_} <br /> I <br /> SepticTank (Specify Requirements) ------------------- -------------- --------------------------------------------------------:----------------_- ---------------------- <br /> Disposal Field (Specify Requirements) _ -- ---------- -------- <br /> J h <br /> ------------- rt 2` r----- a-- <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 San 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 shall not employ any person in such manner <br /> as to become subject to Workman's pensation laAiflornia." <br /> Signed ----- -------------- - - - ---------------- -- - -----. Owne <br /> By ------ --------- ---------- ------ -------- e <br /> ---- ----- ------------------------------------------ <br /> (If other than owner) <br /> FOR .DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BYDATE ?--------------------- <br /> ----------------------------- <br /> BUILDING PERMIT ISSUED -----------_'-------------- -------DATE ---------------------------------- <br /> ----------------------------------------------------------------------- --------- <br /> ADDITIONALCOMMENTS -----------I------------------------------------------------------- ------ -----------------------------------------------------=---------------- ------ --- <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> -- ----------------------------------------------------- ----------------------------------------------------------------I----------------------------------------------------------------- <br /> i <br /> Fina! Ins pectionby: ---------------------------------------------------------------------- -------.Date - - - ` ----------------------------- <br /> SAN <br /> - -- --- ----------SAN JOAQUIN LOCAL HEALTH .DISTRICT <br /> r <br /> E. H. 9 1-'68 Rev, 5M, <br /> i _ <br />