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FOR OFFICE USE: r/4 R Il S3 /Z/-Z,7 6 <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) <br /> _____________________________I This Permit Expires ] 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 -------!A_A,9_,4r--- r-,Oa-���--------------------- ---------------------CENSUS TRACT -----------------•-------- <br /> Owner's Name __Phone_____________________ _ <br /> Address -------j- �6_V---j...& --. Cit <br /> Contractor's Name -__--. ' ' License # ----------------------------- Phone ______________________________ <br /> Installation will serve: Residence ® Apartment House ❑ Commercial ❑Trailer Court I❑ <br /> Motel ❑Other -------------------------------------------- <br /> Number of living units_____________ Number of bedrooms ___ ------Garbage Grinder ---------.-- Lot Size ?0t-.A7-0---------------- -------- <br /> Water <br /> --.Water Supply: Public System and name --------------------------------------------------------------------------------------------------------------Private ] <br /> Character of soil to a depth of 3 feet: Sand❑ 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 f ] SEPTIC TANK f ] Size------------------------------------------------ Liquid Depth -------------------------- <br /> Capacity <br /> -----------________-_____ <br /> Ca acitY ------- Type -- - - ------ Material---------------------- No. Compartments -- ---------------- - <br /> 0 <br /> Distance to nearest: Well ----------------------- ------------Foundation ---------------------- Prop. Line -___-.___-__.___.-. <br /> LEACHING LINE [ } No. of Lines __---------------------- Length of each line--------------------_------ Tota( 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 �[] <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} - _.---- -t �-• 'J--, -- - -- ----------------------------------- <br /> �► ------------------------7•f�----��)--------------------------- --------------------_--------------- <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 sub'e t to fW kman's Compensation laws of California." <br /> Signed _. . - _. sl - Owner <br /> BY ------- ------------------------------- ------------------• Title -------'------------- <br /> ------------------------------- -------------------------------------------- --------------------------- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BYDATE <br /> --------- -------------- ------ <br /> BUILDING PERMIT ISSUED ------------ -- - ------------------------------------ <br /> --------------------------------DATE --------------------------------- - <br /> ADDITIONALCOMMENTS ---------------- -------------------------------------------------------------- --------------------------- --------------------------------- <br /> ------------------- —-------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> --------------------------------------------------- --- <br /> - ------------------------------------------------------------------------------------------------------------------------------------------------- <br /> rm-Z --------------- ---- <br /> Final Inspection by: -- �� .r ��r ------------------ ------------------------------------------------Date --- ---------------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />