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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT t of 7 7Permit No, ------- ----- --- <br /> - -- <br /> (Complete in Triplicate) <br /> -- ------ - ---------------------- - --------------- Date Issued <br />( <br /> --------- <br /> -------__--_---.------------------_-------. r This Permit Expires t 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 compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> CENSUS TRACT -------------- <br /> JOB ADDRESS/LOCATION _] 7f ?`.� 1 _ <br /> Owner's Name ----------Phone_� --------b" ------ <br /> - --�1---� fit-----���h-�.�------------ ---------------- --------- -----� . -----�•---- -- <br /> Address ------- Z_c------- D--- ---I2 ------------------------------------------ --- City -- RP2 = I <br /> Contractor's Name ------ - --------------------------------------------------------License # ---------:------------- Phone <br /> Installation will serve: Residence Cl''rGpartment House❑ Commercial :E-]Trailer Court '❑ <br /> I <br /> I <br /> Motel F-1Other ------------------------- ------------------ ,p �{ <br /> Number of living units:.-----[_---- Number of bedrooms -----/-----Garbage Grinder --".-- Lot Size ----- ----_____________.______________ <br /> Water Supply: Public System and name ---------------------- ----------------------------------------- ------------------------------------ Private C <br /> # Character of soil to a depth of 3 feet: Sand' Silt❑ Clay ❑ Peat Sandy Loam [] Clay Loam F1 { <br /> .p ❑ �. ,a T❑ <br /> - Hard an Adobe Fill Maferial - _:___-._ 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 -------------------------- O <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 ---------------------------- <br /> D' Box .----------- Type Filter Material --------------------Depth Filter Material --------------------•---------------•-- <br /> _- ,. ----------' Foundation ---- -�'_ p"fy ------------------------ <br /> D�isfance fo neares#: 1Nell- ____: _ Pro er Lined <br /> SEEPAGE PIT [ ] Depth ._._- Diameter ________________ Number ---------------------------- Rock Filled Yes C] No 0 <br /> WaterTable Depth ---------- -------------------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well ___ __________________________________••Foundation .------------------- Prop. Line --------..______-___-- <br /> It <br /> REPAIR/ADDITION(Prev. Sanitation Permit r# --------------------------------------------- Date ----------!___________--_---------) <br /> Septic Tank (Specify Requirements) ------------ ----T--- --------------------------------------------------------------------------------•- <br /> Disposal Field (Specify Requirements) .--------GO:----- --------------------------------------------------------------------- --------------- <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 San Joaquin Local Health District. Home owner or licen- <br /> sed agents signaturecerci 'es the following: <br /> "I certify that ' t p orrnonce of o for which this permit is issued, i shall not employ any person in such manner <br /> as to become Ie s Comp sati.on laws o California." ,- <br /> Signed""t. --- - --- Z----- -- ------ ---- Owner <br /> ------------------------------------ Title ------------ - -------- ---------- - <br /> ------- -------------------- <br /> (If other than owner) <br /> FOR PARTMENT USE ONLY <br /> APPLICATIONACCEPTED BY _-. -___ ___ - ---- ---- --- --------- -------------------------------------------------- DATE --- ------------------- <br /> BUILDINGPERMIT IS5UED ---------- -- ----------------------------------- - ------------------------------------ -- ------------DATE ------------------------------------------- <br /> sADDITIONAL COMMENTS ---------------------- --------------------------- --------------•---------------------------------------- --- ----------------------------------------------- <br /> ----------------------------- <br /> -------- -------------------------------- <br /> -------------------------------------------------------- <br /> --------------------- <br /> ------------------ ---------------- - -------------- ---------- ------------------------------------------------------------------------------------------------------------------ <br /> ------------------------------------------------------ - -- --- - - - - - - <br /> - ---- ---------------------------------------------------- ------- ---- ---- -- <br /> --------------- <br /> Final Inspection by: ------------- ------------------------------------------------------------Date --- .J -- --- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> I <br /> ] E. H. 9 1-'68 Rev. 5M <br />