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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> Permit No. <br /> -------------- ----------------------------------------- <br /> (Complete in Triplicate) <br /> ----------------------------------------------- <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 permit to construct and install the work herein <br /> described. This application is made in compliance with County Ordinance No. 5.49 and existing Ryles and Reglulations: <br /> JOB ADDRESS/LOCATION . l-_/--f - :-. t- J t°' � AKTIROXA7C <br /> Phone <br /> Owner's Name ----- r--------- <br /> Address ----- ------ J ,itY --------- --- --------------------- - - <br /> --- <br /> ------------------- <br /> Contractor's Name 0,07_-.---------------------------------------License #` 9• j• Phone a - .��_. <br /> Installation will serve: Residence' y4partment House❑ Commercial ❑Trailer Court 0 <br /> 4tel7__Other ------------------------------------•-------- <br /> Number of living units:---1------ Number of bedrooms , ------Garbage Grinder IV--_::F_ Lot Size -���"����`---------••- <br /> Water Supply: Public System and name -------------------------------------------------------------------------------------------------------------- <br /> --------------------- -------------------------------------------------------------Private K <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ,E] Clay Loam (a� <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 TANK;{ Size-. - .,X-->��--------------------- Liquid Depth - -----...---------- ty <br /> CapacityX�4__ __..-_ TypeI'av/ Material_ 1JCr---- No. Compartments ___ -.__.....-__ A <br /> ° _Foundation --+ -- ---------- Pro Line - --f�__�.-,------ <br /> Distance to nearest: Well __�j�1 ___________________ � p• � -- <br /> ---------------- Length of each line-,/49L?-� ..--------- <br /> ----------- Total Length - <br /> LEACHING LINE � No. of Lines __// <br /> 'D' Box ? -- Type Filter Materialf /e4,,1 eDepth Filter Material -- ----_______________________.--.----- <br /> ` __ Foundation .__________ Property Line __� -- <br /> Distance to nearest: Well �Q-------------- ��` p �Y --� -•-•--------- <br /> SEEPAGE PIT Depth __. ��"___ Diameter ,����-- Number _�� ____________________ Rock Filled Yes, No i❑ <br /> 1_�1 _�" ---Rock Size---- �. ---------- <br /> Water Table Depth - <br /> �. <br /> Distance to nearest: Well ___f ..................-.....Foundation --- - ____ Prop. Line _ _ .__._-- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# .-.----------------------------------------- Date ---------------- -----) <br /> Septic Tank (Specify Requirements) ----------------------------- --------------------------- ---------------------------------------.----------------------- <br /> Disposal Field (Specify Requirements) •--------- - ----------------------------------------------------------------------------------------------- <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------- <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. Florae 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 become subject to Workman's Compensation laws of California." <br /> Signed --------------------------------------------------------------------------------- --------------- Owner <br /> By ----- -------------------------------------- <br /> --------- Title -------- -------------------------------------------------------------- <br /> (if other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY.-- - - - -- - - ------------- -------------------------------------=-------- DATE _-_ ._ -' - - <br /> BUILDING PERMIT ISSUED ----------------------------------- --------------- <br /> ------- --------DATE ----------------------------------•-------- <br /> ADDITIONALCOMMENTS -------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ------------------------------------------------------------------------------------vi _ <br /> ----- <br /> ------------------------------------------------------------------------------------------------------ <br /> ----------------------------------------------------- - ----------R--------------------------------- <br /> ------------------------------- --- -- -- -------- --- <br /> - <br /> ----- <br /> Final Inspection b Date '______"_ ._ -- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />