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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT j <br /> --------------- ------ Permit No. _ = <br /> ------------ <br /> (Complete in Triplicate) <br /> _______ ______________ This Permit Expires i Year From Date Issued 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/LOCATION . _�� �__I _A&�I4:-_._______ - ___CENSUS TRACT __________________________ <br /> Owner's Name J � ----�v - �_ Phone ------------------------------------ <br /> Address -----------------------------------------------------------------------• City _=---------------------------------------------------------------------- <br /> Contractor's Name ------ <br /> _A_ ------------ License # 7�-! _ Phone�f`�' 7� ` <br /> Installation will serve: Residence rVApartment House❑ Commercial ❑Trailer Court ;❑ <br /> Motel ❑Other-------------------------------------------- <br /> Number of living units..---/---- Number of bedrooms --_=f-_---Garbage GrinderW- -AO- Lot Size '_-_----_- i <br /> Water Supply: Public System and name ---------------------------------• -------------------------------------••-----------------------------------.Private j <br /> Character of soil to a depth of 3 feet: Sand [-] Silt C1 Clay ❑ Peat❑ Sandy Loam [] Clay Loam <br /> Hardpan ❑ Adobe ❑ Fill Material ------------ If yes,type ____________________________ Y <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 pub[' sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK Size__ �s 1 <br /> ------ -- • - Liquid Depth �` ------------------ <br /> Capacity11 ____._ Type 0??'Materiall No. Compartments --- ------------ <br /> ----------------- <br /> Distance <br /> __-. _-_ - <br /> Distance to nearest. Well ----- -- Foundation _____ Prop. Line _- � <br /> �'� ------------ , <br /> e <br /> LEACHING LINE No. of Lines -----9-________ ____ Length of each line._ g <br /> - -��'-------- ----- Total Length _._ 3J-�.--------- <br /> -- ' <br /> D' Box e.->- Type Filter Material/1 . _Depth Filter Material ,e1,�---y________________ __ _________ <br /> Distance to nearest: Well __ _ Foundation <br /> ----.---__ Property Line".�� <br /> SEEPAGE PIT [ ] Depth _ ._--- ___ Diameter-4 Y/.-Z. Number -------A---------------- Rock Filled YesA No C3 <br /> Jf1� g5. Water Table Depth ------��- ------------------ <br /> ---------Rock Size 1------------------------- <br /> Distance <br /> ------------ - ------Distance to nearest: Well ______________________________________Foundation -------_-- --------- Prop. Line ---------------------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date __________________________________) <br /> i <br /> - <br /> Septic Tank (Specify Requirements) ___-__k___________________________ <br /> ---. -- <br /> DisposalField {Specify Requirements) -------- - -------------------------------------------------------------------------------------------------------------- <br /> a <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ----------------------- ----------------------------------------------- ------------------------------------------ ----------------------------- ------------------------------------------- <br /> (Draw existing and required addition on reverse side) 1� .-A <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 laweof California." <br /> Signed ------------- - -------------------------- -- -- --------------- -------------------- Owner <br /> By --------------------- ------ ---/-------------- ----------Title ----- <br /> (I ther than owner) <br /> FOR DEPARTMENT USE O LY <br /> APPLICATION ACCEPTED- B - ----------------------------------------------- <br /> -------------- DATE . = = <br /> ------------------- ----- <br /> -- ----- <br /> 1"'ING- P€RMIT—t --------------------------i------------------------------------ <br /> ------------------------ --------------DATE ------------------------------------------- <br /> ADDITIONAL COMMENTS ----------------------------------------------------------------- - <br /> ----------- ---------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------- <br /> ------------------------------------------------------------------------------------=------------------------------ <br /> ------------------------------------------------------------------------------------------------------ --- ----- - <br /> ---- ---- - ---- - ---- <br /> Final Inspection by: -------------------------------------------------------------------- ----------- -- -- -- - ---- ----------- �� <br /> Date - <br /> SAN JOAQUIN CAL LTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M i <br />