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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> ----��=�-`------'�------•- .��- ,. ., Permit No- --------------------- <br /> (Complete <br /> - ------------ --(Complete in Triplicate) <br /> --------- v <br /> Date Issued �1.-_ -_`_�_.. <br /> -- --------------------_--- ----------- -------------_ This Permit Expires 1 Year From 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 ------�4,---- T _xe------------------- -------------------CENSUS TRACT -------------------------- <br /> Owner's Name -- y r !(/ .E' _ <br /> ------------------Phone ------------------------------- <br /> Address -- _5VA/-Wr�------------------------ -------------------------------------------------------- City - <br /> Contractor's Name 1/` -- -------- eW_ -------.License # _ �' --- Phone <br /> Installation will serve: ResidenceeK Apartment House,❑ Commercial :❑Trailer Court ;❑ <br /> Motel ❑ Other -------------------------------------------- <br /> Number of living units.--�_._-__ Number of bedrooms ----Garbage Grinder Lot Size 2�=,5_-----._-. <br /> Water Supply: Public System and name ------------------------------------------------------ -------------------------- ---------•-------------------Private P <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 [ ] SEPTIC TANK'[ ] 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 line---------------------- ----- Total Length _----------.---.------..__-- Q <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 ❑ No i❑ <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) ---P-_-A0;V--------/MQ------- C1- --.--..�9_ --------- <br /> ---`V-4c-kl--- --------------- r`------------------------------------------------------------------------------ ------------------------ <br /> ----------- --- ---------------------------------------------------------I------------------------------------------------------- ------------------------------------------------------- <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 licen- <br /> sed agents signature certifies the following: <br /> "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner <br /> as to becomes lett to orkman's Compensation laws of California." <br /> Signed I Owner <br /> BY -------------------------- --------------------------------------- ---------- ------------ --------- Title --------- ----------------------- ----------------------- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY - --------------------------------------------------- DATE 3- 3 o---------------------------- <br /> BUILDING PERMIT ISSUED ---_ -- <br /> -------- --- ------------------ <br /> ADDITI A CO MENT�_ ,94",k ---- 4 ------------- . . ..t.-. -- - <br /> I L��` - '- ------------------------------------ <br /> ----------------------------------------------------------- --- -------------------------------- <br /> -------------------------------------------------------------- -- - ----- <br /> ---------- <br /> - - ------------------------------------------------------ ---------- ---- ----- <br /> Final inspection bY: Date 3 -f Z ----- ----- <br /> ---------------------------------- ----- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M, <br />