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FOR OFFICE USE: <br /> APPLICAT ON FOR SANITATION PERMIT (� <br /> ----------------- --- {Complete in Triplicate) Perm it No. _ _ (a <br /> ------------------------------ <br /> • Date Issued <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 /> . tt `` V <br /> JOB ADDRESS/LOCATION _ =l_b-_____ 1 a_e_ rr1r� __.-- ------ --- CENSUS TRACT ---------------------___-- <br /> Owner's Name <br /> �- ----------, <br /> ------ -_------------Phone -- -. 15_4A?--- <br /> Address dqq <br /> 6s- -- ------ ------------------------------------------- City Q� <br /> Contractor's Name -------------------1------------------------ ,_ .. -__�:__. m------------------License /�--- Phone V -_ ---- 9 c�� <br /> Installation will serve: Residence ❑Apartment House'E-] Commercial❑Trailer Court F1Motel F1 Other ---------------•---------------------------- s <br /> Number of living units:-/-------- Number of bedrooms -2-- __Garbage Grinder ------------- Lot Size _ ' _ _____________________ <br /> Water Supply: Public System and name ---------------------- ------- ---------------------- --------------------------------------------------Private <br /> Character of soil to a depth of 3 feet: Sandg Silt .Clay ❑-- Peat❑ - Sandy•L-oom.-D.—Cla_y-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'[ ] Sile-•-------------------------------- <br /> --- Liquid Depth ------------------------- <br /> Capacity ----------- - <br /> ---------•----------_-_-Ca acit _______ T "- Material:-------------- _ -I-, No. Compartments <br /> Distance to nearest: Well -_------------------------------------Foundatio -_ Prop. Line ---.______________ <br /> LEACH'2"G LINE [ J No. of Lines ______ _ Length­o each line________t _.______ Total Length ,--___-____•________________ <br /> D' Box ------------ Type Filt rMaterial..------------------Depth Fit er Material ___-------_-.------------------------------- <br /> Distance <br /> - _---------------------------Distance to nearest: Well -------- -_�,_______ Foundation '_______ ________________ Property Line .__..._.........__....__ <br /> SEEPAGE PIT [ ] Depth '----`----------"--- Dia 0ter ----_-_1.:------ Number ---------- ----------------- Rock Filled Yes (] No i❑ <br /> Water Table Depth --- ------------------ Rock Si <br /> ------------ <br /> F � <br /> Distance to nearest: Wel -----------------------------------=rounda ion -------------------- Prop. Line .......•-------------- <br /> REPAIR./ADDITION(Prev. Sanitation Permit# ____ ___ __________________________________ Date ____ _____________________-______) <br /> Septic Tank (Specify Requirements) -------------- ---------- <br /> Disposal Field (Specify Requirements) ---_------------------------______---------____ _____ <br /> -- - - -- ---------- --------------- <br /> ----------------------------------------- <br /> ----------------- - - --------- <br /> rvs /1 ---------dao- <br /> f ;Y --� <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> (Draw existing and required addition on reverse side) <br /> 1 hereby certify that I have prepared this application and-th•at -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'fallowing: <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 become subject to Wor man's Compensation laws of California." <br /> Signed - ------- --------------------------- <br /> --- Owner <br /> ------ Title ------------- ---- ---- --------------- - -- --------------- ------ <br /> (I other than owner) <br /> FOR DEPAitTMENT USE ONLY <br /> APPLICATION ACCEPTED BY = - ----- DATE ------ ------------ ----------------- <br /> BUILDING PERMIT ISSUED -------------------------------- R - ''------------------------DATE ------- ----------------------------------- <br /> ADDITIONAL-COMMENTS ------------------------------- ' ` '' , ,, _e I-.-- . � <br /> ---------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------- <br /> - - <br /> ------------------ ------------------------------ - -- ------------------------------------------------------------------ ------------- ------ <br /> --- --- ------- <br /> —27---------------- <br /> Final Inspection b -- - -------------------------- ------------------------------Date <br /> ----- - - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />