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FOR OFFICE USE: 10-7 IP- woa <br /> APPLICATION FOR SANITATION PERMIT <br /> Z f{ Permit No. <br /> (Complete in Triplicate) <br /> ------------------------------------ -------------------- This Permit Expires 1 Year From Date Issued <br /> 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/LOCA/TION ._Rrp t>--- s��e ISS-- -- ----------------- ---- ------------------CENSUS TRACT --------------•--- ----- <br /> Owner's Name ---X F---h-'-IC------- <br /> --- `--/A---10--7--------------------------------------- -------------------Phone ----------- ------------------_--- <br /> Address ----c11glll ±` ---------------------------------- City - <br /> Contractor's Name _____A/AI----4tl� ' -_ --------------------------------------License # �s5;°(�-d��- Phone <br /> Installation will serve: Residence Q p rtment House❑ Commercial ❑Trailer Court i❑ <br /> Motel ❑Other -------------------------------------------- <br /> Number <br /> ------------------------------------------Number of livingunits:__-. _ __....Garbage Grinder _.________ Lot Size �� --- >v <br /> ,�___ Number of bedrooms ____ _ _ _•____ __ ______________ L <br /> Water Supply: Public System and name ----------- sT,k',_G�-_ --------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand'E] Silt❑ Clay Peat❑ Sandy Loam ❑ Clay 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 [ ] Size______________________________________________ Liquid Depth -------------------------- <br /> Capacity <br /> _-_____________- -.__Capacity -------------------- Type -------------------- Material--- ----------------- No. Compartments ...................... `o <br /> Distance to nearest: Well ___________________-_____--__-_____Foundation ---------------------- Prop. Line ------ ............... t <br /> LEACHING LINE [ ] No. of Lines _______________________ Length of each line---------------------------- Total Length --____-___..-__---____-----_ v <br /> 'D' Box ____________ Type Filter Material ___________________Depth Filter Material --------------------I........................ j <br /> Distance to nearest: Well ________________________ Foundation ------------------------ Property Line _-______-.-_.-_-__----•_ <br /> SEEPAGE PIT [ ] Depth ---------------- __- Diameter _--_____ --__-- Number _.-------------------------- Rock Filled Yes '❑ No 0 <br /> Water Table Depth ------------------------------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well ----------------------------------------Foundation _--__- _________ Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) <br /> SepticTank (Specify Requirements) ---------------------------------------------------------------------------------------------•-------•--------------------------------.----- <br /> Disposal Field (Specify Requirements) ------------------------f�•.1-------------------------------------------------------------------------------------------------- <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 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 two Workman's Compensation laws of California." <br /> 4 Signed ----- .4-4<-- `" 1�.�-------------------------------------------------- Owner <br /> By --------------------------------------------------------------------------------- ---------- Title ------------------------------------------------------------------------ <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ------------------------ --------------------------------------------------------------------------. DATE ------------ -------------------------- <br /> BUILDING PERMIT ISSUED ----------- -------------------- --------------------------------- ----------- ----------DATE <br /> ADDITIONALCOMMENTS ------------ ------------------------------------------------------------------------------------------------ --------- -----------=--------------------------- <br /> -------------------------------------------------------- ----------------------------------------------------------------------------- ------------------- ----------------------------------------------- <br /> --------------------------------------------------------- --------------------•--------------------------------------------------------------------------------------------------------- <br /> ----------------------------------------------------------------------------------------- ------------------------------ -- -- - --------- <br /> Final Inspection by: ------ -------------- -------- - - -------- - -- -4/--(- Date Z <br /> - - ------------- <br /> SAN JOAQUIN LOCAL HE DISTRICT <br /> E. H. 9 1-'68 Rev. 5M C <br />