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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT � <br /> - -- --------- ------------•------------ - Permit No. -- --------- <br /> {Complete in Triplicate) �' f <br /> ---- ---=----------------------------------------------- A�_16_g1 <br /> -- ------------------ This Permit Expires 1 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 /> -------lir.- - ,_.____--CENSUS TRACT ---_ <br /> JOB ADDRESSAOCATION .__ - . � _ __L-S______________ __ 5'4, <br /> Owner's Name ' __Phone-9'-- 6�.-....._ <br /> rr `` - --U/ 0 - ` qqn,, <br /> Address ------------------------------`T" _ --- -- ---- .eL[17Cit4 - <br /> Contractar's Name License # t ��_-.--_ PhoneYjWW'67 <br /> ----•• - --- <br /> Installation will serve: Residence f"`Apartment House-E] Commercial ❑Trailer Court ;❑ <br /> Motelp Other -------------------------------------------- <br /> Number of living units:---{_------ Number of bedrooms _3------Garbage Grinder ------------ Lot Size ----------- --------------- <br /> WaterSupply: Public System and name -------------- --------------------------------------------------------•--------------------------------------_PrivateX <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay [3 Peat❑ Sandy Loam�< Clay Loam F] <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 TANKDq Size------ x �J --7� <br /> ---- ---------------------------- Liquid Depth --- ------ --------- � <br /> JgacCapacity .----- -- Type ' �1"_� _ Material- No.�Compartments --- --_-_-.__. <br /> Distance to nearest: Well -----4----______ -- <br /> ------------ Foundation .---?----------- Prop. Line -----1r-_ , <br /> i <br /> LEACHING LINE No. of Lines ._--.-5-------------- Length of each line_------�------------ Total Length ---;�i5p"O---_------_- <br /> 'D' Box ----- Filter Material -lti4 ____Depth Filter Material -----_/_P------------------------------ <br /> Distance to nearest: Well ------S�_�f_---- Foundation -----o�P------------- Property Line ------- <br /> --------------- <br /> SEEPAGE <br /> ------SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- `Number ----------------------------- Rock Filled Yes ❑ No i❑ <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 /> DisposalField (Specify Requirements) ---------------------------------------------------------------------------- --------------------------------------------------------- <br /> ----------------------------------------------------------------------------------- --------------------------------------------•-- ------------------------------------------------------------------- <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 /> BY ------- - --- - ------- - Title ..---- ----- <br /> (If other n owner) <br /> FOS DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY --- ------------------- ------------------------------------------------------------ DATE _1�"/ <br /> BUILDINGPERMIT ISSUED .------------------------------------------------------------------ ------------ --------------DATE ---------------------------------------•--- <br /> ADDITIONAL COMMENTS - <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ----------- <br /> --------------------------------------- ------- -----------=-------- - --------------------------------------------------------------------------------------------- <br /> Final Inspection by: — ---------------.Date - _--- <br /> ---------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H, 9 1-'68 Rev. 5M <br />