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FOR OFFICE USE: <br /> a�� ------------------------------------ APPLICATION FOR SANITATION PERMIT <br /> ------- Permit No. _ <br /> __7S_S_ <br /> ;Complete in Triplicate) - <br /> --- ------------ -------------------------------------- S✓ <br /> -------------------------------------- This Permit Expires 1 Year From Date Issued 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 <br /> with County Ordinance No. 549 and existing Rules and Regulations: <br /> J08 ADDRESS/LOCATION ._, '�z ---- ---- t_L- <br /> ------g- --------------CENSUS TRACT --------------..------_ <br /> /} / <br /> Owner's Name ---a -------`-t---�1�' <- --------------------•----------------------------- Phone = C?" . <br /> Address c7'- ' % ' --=----- - 0�=�' <br /> city ------------------------------------ - - <br /> Contractor's Name ----f __ ______ � � ' !__`- ________________________License # -_ �� Phone 9P, __ <br /> Installation will serve: Residence R Apartment House^❑ Commercial ❑Trailer Court !❑ <br /> Motel ❑ Other -------------------------------------------- <br /> Number of living units:./------- Number of bedrooms _-3------Garbage Grinder ------------ Lot Size ____________________________________________ <br /> Water Supply: Public System and name --------------------------------------------------------------------------------------------------------------Private [? <br /> Character of soil to a depth of 3 feet: Sand'9 Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe ❑ Fill Material ____________ If yes,type ____________________________ <br /> (Piot 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 --------------------------IN <br /> Capacity -------------------- Type -------------------- Material---------------------- No. Compartments -----------------.----V1 <br /> Distance to nearest: Well ------------------------------------Foundation ______________________ Prop. Line ______________________VJ <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 ❑ No CQ <br /> Water Table Depth ------------------------------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well ________________________________________Foundation ------------------ Prop. Line ____ ............. <br /> REPAIR./ADDITION(Prev. Sanitation Permit# ...._---_----------------------------------- Date _____________._______-____________) <br /> Septic Tank (Specify Requirements) ---------------- - -----------�---'` ------ ` , -/-`..... <br /> Di s osal Fi Id (Specify Requirements) ____ ----------------------- ___ -i--_--____C�_�__�`��_�_-__.l�y�-/���- <br /> - ------------------------------ - <br /> -- <br /> --------------------------------- ---------------------- -- ---------------------------------------------------------------------------------------------------------------------------------------------- <br /> (Draw existing and required addition on reverse side) <br /> 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 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 -------', ------------------ Owner <br /> BY •- `--------- ;Title -------------------- <br /> - - ------------------------------------- <br /> ----- --------------------------------------------- <br /> (If otherfhan owner) <br /> Z�FOLDPPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY --- 0__ _/<2e------------------------------------------------------------- DATE ---- <br /> BUILDINGPERMIT ISSUED ----------------------------------------------------------------------------------------------------------DATE ------------------------------------------- <br /> ADDITIONALCOMMENTS ---------------------------------------------------------------------•------------------------------------------------------------------------------------ <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> -- --------------------------- --- -- - ------- -- -- --- ---- - --- - <br /> --------------------- - -- -- --- ------- --- - --- -------------------------------------------------------------- - ------- ------------------------ <br /> Final Inspection by: -------------------- Date <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />