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1 <br /> FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit No. --- ------ <br /> ---------- ----- Date Issued , x_73 <br /> --------------------------------------------------------- This Permit Expires 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 compliance with' County Ordinance No. 549 and existing Rules and Regulations. <br /> JOB ADDRESS/LOCA T �2�� <br /> - - -------------------------------------------- . "CENSUS TRACT <br /> Owner's Name '- -�----- - --- ---------------------------------- -------------Phone ------ <br /> Address r� ;7 -------- �- - '---------- --- - -------- cit ------•------ <br /> --- ----- ------------------- <br /> "" - <br /> Contractor's Name - ---- �1!s=`-'�'�'�--F- ---- --------------- ------------------- - - --License # Izr��_ __ Phone ------------------------------ <br /> Installation will serve: Residence Apartment House❑ Commercial :❑Trailer Court ;❑ . <br /> Motel F-1 Other , -�__fd ^-�- <br /> Number of living units:_________ Number of bedrooms ----//__...Garbage Grinder ------------ Lot Size _________________________________________ <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 'EQ Fill Material ------------ If yes,type ---------------------------- SIV <br /> (Plot plan, showing size of lot, location of system in relation tcr wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank,or seepage pit permitted if ffp//ublic sewer is available within 200 feet,, <br /> PACKAGE TREATMENT, [ I SEPTIC TANK'[ ] Size__ 1. _lam___--�___--- ____ Liquid Depth f_�_____-_. <br /> � . <br /> ----------- <br /> Capacityf TYe4 `- / <br /> .Material _0-6-)�----- No. Compartments --------_ ........ <br /> Distance to ne rest: Well --------- <br /> ______-__Foundation ____--// - Prop. Line ----��-_ <br /> l -� _� 'length of each Eine-___ ________ Total Length ____l_A__a - <br /> LEACHING LINE [� No. of Lines ---- / - ._... <br /> 'D' Box __________ Type Filter Material _ _-----_----------Depth Filter. Material _______ _____________________ <br /> / Distance to nearest: Well __._____J _ _ ____ Foundation � _ __ _____:.__ Property Line <br /> t/ <br /> SEEPAGE PIT [ ] Depth -----, j Diameter. _______ 36__ Number ------------ � -------- Rock Filled Yes No �] <br /> Water Table Depth � - -------_Rock Size -----/�V_ X <br /> Distance to nearest: Well _________ _______________Foundation ------ 29�__��___ Prop. Line ____ �....... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ------••--------------------------) <br /> SepticTank (Specify Requirements) ---------------•-1--;----------------------------------------------------------•------------------- ----- --------------------------- <br /> Disposal Field (Specify Requirements) ----------- -------------------------------------------- -------- <br /> --------------------------------------------------------------- ---------- <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 Sate Joaquin j <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 ompensation 411aw of California." <br /> Signed ------------------------------------ <br /> ---------------------------------- --- ------ .....Owner --------- <br /> . _ <br /> ` . Title YY- � <br /> - --------------- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY __ _ -____ /E 3 <br /> ----- -- - -- -- ------------- -------------------------------------------------• DATE --�-6--------�'--•---- - • --------- <br /> BUILDING PERMIT ISSUED ------------------------------------------_ ------------DATE <br /> ADDITIONALCOMMENTS --------------------------------------------------------------------------------------------------------------------------------------------•-•---------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> -- ---------------------------------- ------------- ----------------------------------------------------------------------------------------- ---------------------------------------------------- <br /> ---------------------------------- <br /> -- ---- ------------------ - - <br /> --- �fi <br /> Final Inspection by: - - -- -�"'t°�� --=----------------------------------------------- I <br /> ----- -----------.Date�-- <br /> ----------------------------- ---------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />