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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> Permit No. ___�_3_~ <br /> ------------------------------- -- ------------------ (Complete in Triplicate) <br /> ----------- ---------------------------------- P <br /> - Date Issued <br /> This Permit Ex ires 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 complian a ith County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCA CENSUS TRACT _S� ---•---------.. <br /> Owner's Name ----- R. ----� �-"- ---------------------- Phone <br /> - - ----------- -- <br /> Address Cit -------------------------------------- -----•-.----- <br /> d:�r----- --- - ------ ------ Y <br /> r ------.License # l��_ --- Phone ------------------------------ <br /> -Contractor's Name __.._ =_ - <br /> _4_ 4---- <br /> Installation will serve: Reside nce*Apartm ent House❑ Commercial ❑Trailer Court <br /> Motel ❑Other -- #:-------------------- -- <br /> Number of living units:----- ----- Number of bedrooms ___`.Y.Garbage Grinder ------------ Lot Size _- '--<'--� ------- <br /> Water Supply: Public System and name _ _____ <br /> pp Y Y ------------------I-- '--------------- ------------------------------------------------------------------Private ® , <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam PV Clay Loam ❑ <br /> Hardpan ❑ Adobe ❑ Fill Material ------------ if yes, type ---------------------------- <br /> (Pl'ot 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,) . . .x ( <br /> PACKAGE TREATMENT f ] SEPTIC TANK'[ ] Size--------------------------------- ------ Liquid Depth --------------------------- <br /> l/\l <br /> Capacity Type --------------------- Material-------- ------------- No. Compartments ------ o <br /> Distance to nearest: Well =-"'-----_---'- 3---------`-------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 ----------------- ------- <br /> SEEPAGE PIT Depth -- Diameter ____ __."______ Number _.__:--- ___------------- Rock Filled Yes .0 No <br /> [ ] p <br /> I ,f <br /> Water Table Depth -------------------------------------------------Rock Size -------------------------------- <br /> I <br /> � � Foundation Prop. Line ______________________ <br /> Distance to nearest: Well ____�-�'__-___,_ ------------- <br /> --------------- --- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ------- ------i ---------`- Date ------ --------------------------- <br /> ) <br /> ... ___..__..,.________�_________________ <br /> . --`_ __1--j__________________________________r^__ <br /> Septic Tank (Specify Requirements) -----`---- <br /> D' osal Field {Specify Requirements) G ! „ --- <br /> re ----- <br /> -------- ---- - <br /> ------------ ---------------------- <br /> _(Draw existing and required addition on reverse s d a}� <br /> E I hereby certify that 1 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 thework-for which this permit is issued, Jshall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California.” <br /> Signed - ----------------- ------------------------------------- ------ <br /> Owner ---- <br /> Me -- - <br /> ----- ---------------------- <br /> (If other than owner) <br /> FOR .DEPARTMENT USE ONLY <br />' APPLICATION ACCEPTED BY -------- -- - ----- -- ------- DATE __ -%?_-__- 73_ __•-------- <br /> -- -- - - -------- - <br /> - -=----------------------------------- -- - <br /> BUILDING PERMIT ISSUED ----------- ----------------------------- -------DATE ------------------------------------------- <br /> ADDITIONAL COMMENTS -------------------------------- -- ----------------------- <br /> ----------------------------------------------------------------- <br /> ------------------------------------------------------------------------------------------------------ <br /> G1 <br /> ----. ------------------------------------ ---------------------- --------------------------------------------------------------------------------------------------------- <br /> -------- ------------ <br /> ' — --- -� � <br /> - - ---- Date - <br /> Fina! Inspection bY- --------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M. _ <br />