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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> :.......................................... ... 5.�-J? <br /> ;Complete in Triplicate! Permit No. <br /> ......................................................... This Permit Expires ] Year From Date Issued <br /> Date Issued <br /> Application is hereby made to the San Joaquin Local Wealth 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 /> yy <br /> .E013 ADDRESS/LOCATiO1--33. I1__.-. ..............................................CENSUS TRACT ........._..... ........... <br /> Owner's Name .. .. .. .. ,r'�-.-- .... ..... <br /> � ..................•_... � ..Phone .........................-.-....-... <br /> Address ..._.... cG.'' . .... !--,r. - ---//�� •_../..._........... Citystl•...................... .... . ... . .. . . . s <br /> Contractor's Name -1 ... ______ _____• .�:.:�--.(;2� ---------License #, �. _ ._ Phone ................_............. <br /> Installation will serve: Residence Apartment House[] Commercial ❑Trailer Court 0 <br /> Motel ❑Other ............................................ <br /> Number of livingunits:_../.__... Number of bedrooms . ..... ��__.------.-_ <br /> � Garbage Grinder __._._._..._ Lot Size ._��-�-!'• <br /> Water Supply: Public System and name ................. ----•----------------------------------------------•----------------•-•------•••--•---••••-•Private Q� <br /> Character of soil to a depth of 3 feet: Sand 1-1Silt C3 Clay E] Peat E] Sandy Loam (5-- Cloy Loam 0 <br /> Hardpan ❑ Adobe ❑ Fill Material ............ If yes,type ---------------------------- <br /> (Plot plan, showing size of lot, location ofsystem 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'I ] Size................................................ Liquid Depth .......................... <br /> Capacity -------------------- Type .................... Material_--------------..... No. Compartments <br /> Distance to nearest: Well ....................................Foundation ...................... Prop. Line ............. ........W <br /> LEACHING LINE ( ] No. of Lines --------------------_- Length of each line-----..........._,.._....... Total Length ........................... <br /> 'D' Box ------------ Type Filter Material ....................Depth Filter Material -_____•.....................................'7 <br /> Distance to nearest: Well ........................ Foundation ........................ Property Line ........................ - <br /> SEEPAGE PIT [ I Depth -------------------- Diameter ................_Number -.__...-.---_-------_-_. Rock Filled Yes ❑ No C3 <br /> Water Table Depth --- --------------------------•..._....---......Rack Size ......__------ ........... <br /> Distance to nearest: Well ..................................... Foundation _.__ ........... Prop. Line ..................- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# .........._............................. .. Date ..................................) <br /> Septic Tank (Specify Requirements) .........................-------...._..__............ <br /> Disposal Field (Specify Requirements) ...... --- ...... f^L---... ...... ........... <br /> ..............•--------------.............................................:__.C....__:_....... <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 to Workman's Compensation laws of California." <br /> Signed ...__---------------------------\. --...._.._ . Owner <br /> ,. -- -. ....._..-- Title ....... .. ....... <br /> By ..... -- •...........---------------...... :l r... .... Vie <br /> ........................................ <br /> (if other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ........_._C_?/"._. ..........._ ......................................................... DATE ..... ...... <br /> BUILDING PERMIT ISSUED --- fir- --------------- .............................................................DATE .......- -...............I................. <br /> ADDITIONALCOMMENTS .. ....G.:�. �Ci �_ .......... . . .................••-- .....................................................__--------- <br /> ----------------------- -•----..... ......-------------• ---------------------------------•-•---•------•-----------------•--••-..-_..__....,---••-•---.....-•••••....... <br /> Final Inspection---- ..... . ...............•--•--••....-....••----..._..----------------.............__.............-....................................................._.. ...__.._. <br /> •- •• . . <br /> b � ••. 11 ..10.. 7.f.._...._...• <br /> Y: ............ ---••-------...----•--•----..............----...._ .....Date <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H.13 24 1-'68 Rev. 5M 7/72 3 M <br />