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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> �J <br /> ------ - <br /> ------ --- ----------- ----- ----------- - L _. <br /> (Complete in Triplicate) Permit No: <br /> ----------I---------------------------------------------- <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 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�a- - � � 4 _- --------------'` CENSUS TRACT -------------- <br /> Owner's Name ---- ----------------------------------- ------Phone ------- ----------------------- <br /> Address City <br /> p <br /> Contractor's Name --.License Phone <br /> Installation will serve: Residence Apartment House❑ Commercial ❑Trailer Court ;E] <br /> Motel ❑ Other ----- <br /> --- --------- ---------------- <br /> Number of living units:-----I------ Number of bedrooms -- --_Garbage Grinder _ ___ Lot Size __ _____________r----- ------------•--- <br /> Water Supply: Public System and name ------------------------------ •-----------------------------------------------------------------------------.Private <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 <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 seep ge pit permitted if pubflic ewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK f Size - - 4__X��--- ------------ Liquid Depth-_----.____--__-------. <br /> Capacity _ caa _____ Type _ Material_;O - --- No. Compartments <br /> _ a �._--�___.. <br /> r <br /> Distance to nearest: Well --_-- Q__________________Foundation ----___�.�______.__ Prop. Line ----__-_________ <br /> LEACHING LINE [-'� No. of Li s _ r"___-___.__ Length of ac//h��ine..____.�_b-(2------------- Total Length[�- -d----------- <br /> 'D' Box _ . .___ Type Filter Material�--_1V,-_Depth Filter Material _____l__!_____________________.__.._.__-- <br /> t nearesfi: Well __.__ �,I -------- Foundation ____._�- ------------ Property Line. --- <br /> Distance <br /> t � IF <br /> SEEPAGE PIT [ Depth -------- 5_s Diameter ---`t`c ---- Number ----------Q_.-__--j ___ Rock Fi led Yes No i❑ <br /> d � <br /> Water Table Depth -=-----------qb--------------d-------------Rock Size -------- Rock <br /> LV <br /> Distance to nearest: Well ----------- 41 ._________.___-Foundation _jt?----------- <br /> . ft?-_________ Prop. Line ----------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) <br /> Septic Tank {Specify Requirements) --------------------------------------------------------- ---------------------------------------------------- ----------------------------- <br /> Disposal Field (Specify Requirements) --- ---------------------------------------------------------------------------- ----------------------------- --------------- <br /> 4. . <br /> _________________________________________________________________________________________________________________________________________________________________________________________________________ <br /> ---- ---------------------------------- (Draw existing and required add---------- <br /> ition on reverse side) <br /> 1 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, I shall not employ any person in such manner <br /> as to become ct to Workman'" pensation laws of California." <br /> Signed ---- ----- ------ -- - --- ----------------------------------- Owner ]� <br /> ------ Title --- - CJd-f?` ------------------ ---------- <br /> fother than owner) <br /> FOR DEPARTMENT USE ONLY / a <br /> APPLICATION ACCEPTED BY -- --------------------- ------------------------------------- DATE _ - _4.7_--------------- <br /> BUILDINGPERMIT ISSUED --------- ----------- ---------------------------------------------------------------------•--------:-----DATE ------------------------------------------ <br /> ADDITIONALCOMMENTS --------- ------------------------------------------------------------------------------------------------------------------------ --------------------------- <br /> ------------------------------_------------------------------------------------------------------------------------------------------------------------------------------------------ <br /> ______4_.__ __ <br /> Final Inspection by: ------------------------------------------------------------------Date ----- <br /> ------------------------------------ -- ----------- --------- ------ ---- <br /> `� <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />