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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> -------- ------------------ ------- ---------------- __ (Complete in Triplicate) Permit No. <br /> ---------=---------------------------------------- <br /> Date Issued <br /> This Permit Expires ] Year From 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 /I/o�___�`,__ ---------------------------------------------"-----CENSUS TRACT --------------.----------- <br /> - --- -- -- ----- --L <br /> Owner's Name � --- -- ---- '' - ------------------------------- ------ ------------ ------Phone ------- <br /> Address .---�� -- ----Z-1-9 ---------------------------------------------w_ <br /> City --^"-='-- ----------------------------------------------------•------ <br /> Contractor's Name ------------ --- ------------License # ------------------------ Phone ------------------------------ <br /> Installation will serve: Residence R] Apartment House i❑ Commercial ❑Trailer Court ;❑ <br /> Motel ❑ Other -------------------------------------------- <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❑ Clay E] Peat El Sandy Loam -ElClay Loam, <br /> Hardpan,k Adobe.E] Fill Material ------------ If yes,type ---------------------------- d <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 [ I SEPTIC TANK�[ ] Size------------------------------------------------ Liquid Depth -------------------------- • �► <br /> Capacity -------------------- Type -------------------- Material---------------------- No. Compartments -----•------•--------- <br /> Distance to nearest: Well ___ ------------------------ -- <br /> _____Foundation ---------------------- Prop. Line ---------------------- <br /> . - <br /> LEACHING LINE [.] No. of Lines. ._______ _____________ Length of each line------------------------------ Total Length ,_______--_.____---______--- <br /> 'D' Box -------------- Type Filter Material ____________________Depth Filter Material --------------------------------------------- <br /> NI <br /> Distance to nearest: Well ________________________ Foundation Property Line --------------------- <br /> SEEPAGE PIT . [ ] Depth -------------------- Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No C1 <br /> �. 'Water` Table Depth ------------ ------------------Rock Size -------------------------------- <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ---------------------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ------------.-----------------•---} <br /> Septic Tank (Specify Requirements) ------------------------------------ <br /> 01 <br /> Disposal Field (Specify Requirements) _ �lc�-+--�-- -, a�""-�-��----------417-------4-`-- ---'�------------------------------------------------------------------------------------------------------ <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, 1 shall not employ any person in such manner <br /> as to becr/pw subject toWo an's ompensati.on aws o California." <br /> Signe a, -- ------------- Owner <br /> By ----------------- <br /> ------ --------------------------------------------------------------- <br /> --------- Title ---------------- -------------------- <br /> (if other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY _,.k ----------------------------------------------------------------- DATE _ i _` _'_' ------------------ <br /> BUILDING PERMIT ISSUED --------- -------------- ----------------- - <br /> --DATE ------------------------------------------- <br /> ADDITIONAL COMMENTS -------------------------- -------- --------------- ----------- <br /> ------------------------------------------------------------------------------------------------ <br /> ----------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ----------------------------------- ------------------------------------------------------------------------------------ ------- ----Y------- - <br /> ----------------- <br /> Final Inspection by: ___ Date >� - :.�-- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. SM <br />