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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT 11 <br /> -� - 3, <br /> Permit No. _.!- _ � <br /> (Complete in Triplicate) <br /> ------------------------------------------------------- <br /> This Permit Expires 1 Year From Date Issued Date issued <br /> ----------------------------------------- --------------- <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 lin compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOC TION .__�I��/ 1^ - CENSUS TRACT S u <br /> Owner's Name . � -� '�� " Phone --- <br /> Address ------ - --------- -,V_oP-------------- -------- ------------ -----­­ City -------- <br /> Contractor's Name .---- r�`�t ---------.License # 1 � Phone -----------------------------\� <br /> Installation will serve: Residence ( partment House❑ Commercial ❑Trailer Court ❑ r V <br /> j Motel F-1Other ------------- ------------------------ •- �J1� <br /> Number of living units:----!------ Number of bedrooms -----___Garbage Grinder ------------ Lot Size <br /> Water Supply: Public System and name ------------------------------------------------------------------------__----------- ------------Private <br /> Character of soil to a depth of 3 feet: Sand❑ Silt E] Clay E] El - <br /> Peat Sandy Loam lay 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 see ge pit permitted ifs,public XSwer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK![ c Size--qy <br /> ----------------------- Liquid Depth _______` ________________ <br /> Capacity �,p_p4a_______ Type Material__M- __ No. Compartments _-.-_._._____- <br /> i <br /> Distance to nearest: Well ______�' _ _ <br /> a____________________ Foundation -�_Q___r _ <br /> ____ ___ Prop. Line ------- <br /> LEACHING LINE [ No, of Lines __._,:_ ____________ Length of each line_._____ __-�__.______ Total Length _ Q-�_________ <br /> �7 f� <br /> 'D' Box _1-nea-rest: <br /> _- Type Filter Material ------% _-R-----Depth Filter Material ---------/Y ____________________________ <br /> r c � o <br /> Distance Well ______J'C-�___________ Foundation <br /> - - 10- -------- Property Line -,---S--1 <br /> - --------------------- <br /> SEEPAGE PIT [ } Depth ___________________ Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No <br /> WaterTable Depth ---------------------------------------=--------Rock Size -------------------------------- <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line -----____...... <br /> --- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) <br /> Septic Tank (Specify Requirements) -------------------- -------------------------------------------------------------------------------- ------------------------__ <br /> Disposal Field (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 ---"a Ln�@ ------ ---------------------------- <br /> (If other than owner) <br /> 'FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -- f --------------------------------------------------------- DATE ---------------- <br /> BUILDING PERMIT ISSUED - ----------------------------------------------------------------------- -------DATE ------------------------------------------- <br /> ADDITIONAL <br /> -------------------- - <br /> - ----------------------- - --- <br /> ADDITIONALCOMMENTS -------------------------------------------------------------------------------------------------------------------------------- --------------------------- <br /> -------------------------------------------------------------------==----- <br /> r <br /> -------- <br /> 7 <br /> Final Inspection by <br /> - ----------------------------------- _-- <br /> Date - ----- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9' 1-'68 Rev. 5M <br />