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A <br /> FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT _ <br /> = GlyPermit No. - 7- <br /> (Complete in Triplicate) <br /> Date Issued -__�_`��. <br /> This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a per to construct and install the work herein <br /> described. This application is made in compliance with County Ordinance No. 5.49 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION - y- ---CENSUS TRACT ------------------- <br /> - <br /> Owner's Name � �. --- �f� �_e lf'� r Phone <br /> cit h�C�lc1� `= /Z1 <br /> Address -.���--=-- - --�2�-e��--------=---------------/---------- ------------------• y � ��c��� <br /> Contractor's Name ---- - �_"_ -rte f_f1 ----------------------------License .�� - Phone --- --- ---- --.. --. <br /> Installation will serve: Residence PKApartment House,❑ Commercial ❑Trailer Court ;0 <br /> Motel ❑ Other -------------------------------------------- <br /> Number of living units:------1---- Number of bedrooms —5-------Garbage Grinder ------------ Lot Size --------_---------------------_--_------_ <br /> Water Supply: Public System and name --------------------------------•-------------------------------------------------------- ---------------------Private ❑ <br /> Character of soil to a depth of 3 feet: SandA 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{ ] Size------------------------- -- ------------------- quid Depth ----------------------------- <br /> Capacity -- ----------------- Type -------------------- Material- -------------------- o. Compartments -------------•-------- 0 <br /> Distance to nearest: Well ------------------------------- -__Foundatio ---------------------- Prop. Line -_---------_-_-_._..- <br /> LEACHING LINE [ ] No. of Lines --------------------- -- Length of eac line----------- --------------- Total Length ---------------------------- <br /> 'D' Box .----------- Type Filter Material ---- --------------De Filter Material --------------------•-----------------------? <br /> Distance to nearest: Well ----------------- ----- Founda ' n ------------- -----4.Property Line -_----_-----_-----.._-� <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter -- ------------ Nu er ---------------------------- 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# --------------------- - - <br /> ------------------ Date ----------------------------------� <br /> SepticTank (Specify Requirements) ---------------------------------------------------------------------------_------------------------------------------------------------- <br /> Disposal Field (Sp cify Requirements) --------------- -•--------------------------------------c 7 ` ---------------------- --------- <br /> // / ---�----- — ---- ---- ` <br /> ----------- ---------------------------------------------------------------------------------------------------------------------- ----------------------- -------------- <br /> k (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 /> r "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 Workma ' Compensation laws of California." <br /> Signed - --- ----- ------�---- - -- --------- Owner <br /> BY ------ ---- 6---------- Title -.. <br /> ' (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -- --- -- --- --------------------- -------------- -------------------------------- DATE -----jP ----------------- <br /> BUILDING PERMIT ISSUED ---- --- ----------- --------------- ---------------------------------------------------------DATE -------------------------------- ------ --- <br /> ADDITIONALCOMMENTS ----------------------------- ---------------------------------------------------------------------------------------------- --- -- <br /> ------------------------------------------------------ <br /> ------------------------------ -------------------------------------- ------------------------------------------------------------------------------------------ <br /> - <br /> --------------------------------------------------------------------------- <br /> ---- -------------- - - -- <br /> Final inspection by: Date ----6- ,�_ ------------- -- -------- <br /> SAN JOAQUIIv LOCAL HEALTH DISTRICT <br /> E. H. 9 1•'68 Rev. 5M <br />