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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT ...... <br />...........-•............................... . <br /> (Complete in Triplicate) Permit No. .... ....._... <br /> Date Issued ..-�_/9:7 <br />................................................I........ This Permit Expires 1 Year From Date Issued <br /> __.. <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. 544 and existing Rules and Regulations: <br /> 3 10B ADDRESS/LOC ON ...... -------- ... .......... ...... -- ........CENSUS TRACT ................... -----• <br /> Owner's Nom Phone �r� <br /> .................. . ....... V--....._.........-•-- <br /> Address . . /,6go- - ............................ city .._. .... .... ................................................... <br /> r <br /> Contractor's Name ... =. . ...----••--•-._.License # ..� .. -Phone <br /> .............................. <br /> Installation will serve: Residence Apartment House❑ Commercial ❑Trailer Court 0 <br /> Motel ❑Other ------------ ............................... <br /> Number of living units:------- Number of bedrooms _._3.._.Garbage Grinder ............ Lot Size ...... <br /> ._�.. ............... <br /> Water Supply: Public System and name ..... ............_...__...__ ___._..__._...._.........._............................Private <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat❑ Sandy Loam d",Clay Loam ❑ <br /> Hardpan ❑ Adobe ❑ Fill Material ............ If yes,type ............................ <br /> (Plot pian, 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 ifublic sewer is available within 200 feet,) <br /> Ir <br /> PACKAGE TREATMENT ( ] SEPTIC TANK( Size.`?/ --_ _.I____.__x__Jam__ .._.__ Liquid Depth ................. <br /> Capacity _�dQ__ __.__ Type ____.. Materi-a--1 ....... Na. Compartments ............. <br /> / 0 i <br /> Distance to ne rest: Wel! ____.._.�� ....................Foundation .../ p........... Prop. Line .......�9............ 6 <br /> LEACHING LINE No. of Lines _.___ U <br /> [ �-------------- Length of each line._...... ... . .14....... Total Length ------r�?--:'�_..........._. <br /> 'D' Box ...._ ..... Type Filter Material .....45.'..j. :....Depth Filter Material -------/_..f............... <br /> Distance to nearest: Well j�......... Foundation ----e�d.. ......... Property Line •.4-�.................. <br /> SEEPAGE PIT [ ] Depth .................... Diameter ....•........... Number ............................ Rock Filled Yes ❑ No ❑ <br /> Water Table Depth ................................................Rock Size ........--•............... <br /> ... <br /> Distance to nearest: Well ........................................Foundation .................... Prop. Line ....___-..__.__---..._ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ............................................ Date ..................................I <br /> SepticTank (Specify Requirements) -------------------.....-•-•----......_-••-•-..._.....---------•-•---....._........-----------------------.._......----------------------•-- <br /> DisposalField (Specify Requirements) ------------------------- ----•-•---- -------•-----------------•-----------------------------•---------•--------•-- j <br /> .-•--•----- -----------------•-----•-- ------------ ............ ------•------....--------------------------------------------------------------- -------------------------------- <br /> ------------- .......I...... <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 performan of the work for which this permit is issued, I shall not employ any person in such manner <br /> as to become subject to WOr <br /> n's Compensation laws of California." <br /> Signed ---- ---------------------� _ .... �.�---v--------------- Owner <br /> By ........... ................... ..._......------.......... !'................. Title -� ![.........`.'..:-......._+__._....-----....------• <br /> (If other than owner) <br /> FOR-DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ..-- ..---•..................•-----.....---•------•--------•--.. DAT E .."1 ^7-- .._........_........ <br /> BUILDINGPERMIT ISSUED ............................................................................................:..............DATE ..................-----.................... <br /> ADDITIONALCOMMENTS ------------------------------------------------- ............................................ ...................................:........................... <br /> .......................................................... ....................................•--------- .................................... .......... <br /> •_•-__._.............•-----•----------- ..... ...._........ ..... . ..............__..._....._..._....__.._...__..._..._..._._..._............-........ A ...... <br /> ............. <br /> Final Inspection by: _._ _ ---------.........................................................--...Dates ..". ......... ....... <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H.13 24 1-'68 Rev. 5M 7/72314 <br />