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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> --------- - ---------------- <br /> (Complete in Triplicate) Permit No: <br /> ---------------------------------------------------------- <br /> This Permit Expires 1 Year From Date Issued Date Issued - --��-1_ <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/LO� CAr�•-T-1��0Nr,,Z/ d 0? ----- ----CENSUS TRACT -------------------------- <br /> Owner's Name --tel-- ---- ---- ---------- ----1--- --------------------------------- ----Phone ------------------------------------ <br /> Address - ----- 7 - - -------------- City --------- - - ----------------------------------------- <br /> i <br /> Contractor's Name -- ----- ---- ---------------- ---- - ,License #/ ` 97 Phone <br /> Installation will serve: Residence Apartment House❑ Commercial [:]Trailer Court ',❑ <br /> f Motel F-1Other -------------------------------------------- <br /> Number of living units:_____L-___ Number of bedrooms --___Garbage Grinder ------------ Lot Size ____________-------________________________ <br /> Water Supply: Public System and name ___-______________________________._______ __________Private," <br /> --------------------------------------------------------- <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ , Peat❑ Sandy Loam .❑ Clay Loam Z <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.) V <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) Q <br /> PACKAGE TREATMENT ( ] SEPTIC TANK'[ ] Size------------------------------------------------ Liquid Depth ----------------------.--- <br /> Capacity - ---- ------ ------ Type -------------------- Material------- -------------- No. Compartments ------ --------------- <br /> Distance to nearest: Well ____________________________________Foundation ---------------------- Prop. Line -_-________---_______ �1 <br /> LEACHING LINE [ ] No. of Lines ------------------------ Length of eachline---------------------------- Total Length -------.-------.-_________-_ <br /> 'D' Box ------------ Type Filter Material --------------------Depth Filter Material -------------------------------.-.---------- <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 -------------------.--------------I <br /> Septic Tank (Specify Requirements) --------------------------------- ----------------------- ---------------------------- <br /> DisposalFie d {Specify Re uirements) -----------------------------------------r------------------------------------------------------ ------------------------------------- <br /> r <br /> ------------ -d e. 'c�a"Z'�J- --- ------------ ---------- --- ------------------ <br /> rZat, S° <br /> ( aw existing and fieq�ed addition on reverse side) T <br /> I hereby certify that 1 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's Compensation laws of California." <br /> Signed -------- --- - ---------------------- Owner <br /> By --------------- - - ----- ----------------- Title <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY f __ ---- ---- - - -------- =------------------------------- ---- <br /> ------- ------. DATE _ _`� ----------- <br /> - <br /> BUILDING PERMIT ISSUED ---- ------------------ ------------- ---------------------_..---------------------------------------DATE ------------------------------------------- <br /> ADDITIONALCOMMENTS --------------------------------------------------------------------------------------------------------------- -------------------=-------•--•---------------- <br /> -------------------------------------------------------------------------------------------- ------ --- ------------------------------------------------------------------------------- -------- <br /> - <br /> ------------------------------------------------------- <br /> ------------------------------------------- <br /> - <br /> / <br /> ---------- = - --- - ------------ --------------- f� <br /> -gg- //-- - - ------ <br /> Final Inspection by: Date - o . _ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 7-'68 Rev. 5M <br />