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FOR OFFICE USE: s <br /> w , APPLICATION FOR SANITATION PERMIT <br /> - ,. <br /> ------------------ ----- -=-------,---------===-- � ``: '�."_`_�"�` _� =-. � Permit No: <br /> '� (Complete in Triplicate) f <br /> This Permit Expires ] Year•From Date Issued 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 t_ c� <br /> �y ( " - - - ----- ------------------CENSUS TRACT --------------•----------- <br /> ff r� <br /> Owner's Name L /� <br /> +------ - - ---. ------- -- hone �_. <br /> Address -------- -- ------- �y Cit _ <br /> Contractor's Name ----------------------License # �� Phone _ <br /> = 4a-z _" <br /> Installation will serve: ,"Residence Apartment House Commercial ❑Trailer Court i❑_ <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: Sarid'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam .[Ej Clay Loam.E] <br /> Hardpan ❑ Adobe ❑ Fill Mafierial _-_____-____ If yes,'type ________________________ <br /> (Plat plan, showing size of lot, location of system Jin.;relation^ to wells, b-uildings,zetc. 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------------------------------------------------ Liquid Depth -------------------------- <br /> CapacitY ----------------- Type -------------------- Material---------------------- No. Compartments -------------- <br /> D_istx - f. <br /> ance to.: nearest: Well ----- ------- ----------------------Foundation ---------------------- Prop. Line ___________________-__ <br /> LEACHING LINE [ ] No. of Lines ------------------------ Length of each line---------------------__------ Total Length -------------_____-__________ <br /> 'D` Box.---=-------- Type Filter Material --------------------Depth Filter Material -------_--------_------------------.--------- _ <br /> Distance tolnearest: Well ________________________ Foundation - Property Line. __________________._____ <br /> SEEPAGE PIT [ } Depth t Diameter ________________ Number ----------------------------- Rock Filled Yes ❑ No l❑ <br /> '--Water-,Table Depth -------------------- - - — -Rock Size" == =---------------------- <br /> Distance <br /> --=---- --- ----- <br /> - - - - - - - - - - <br /> Distance toinearest: Well ----------------------------------------Foundation -------------------- Prop. Line -.----- ........... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# - ------------------------------------- --- Date -------------____-- <br /> ------- <br /> Septic Tank (Specify Requirements) -----------� P <br /> DisposalField (Specify Requirements) -------------------------------•------------------------------------------------------------------------------------- --------------- <br /> ------------------------------------------- ------------ <br /> --------------______ ____________--__ ---- #'-- - 4- <br /> ________________________________________________________ _,___________-_-__-_____-_..____-______-_____-_____,.___________________-____-_____________________-__-___--______ _______________ <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that 1 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 /> '------- - --------------------------- Title ----- <br /> (If other th owner) <br /> -" ----" FOVDEPAIUMENT LISE'ONLY "-----""- <br /> VOW <br /> APPLICATION ACCEPTE BY . -----------------------'----- = DATE ......67 ----------- <br /> BUILDING PERMIT ISSUED --- -- ------------------- " "- --- -- - - - -------- ----- -: - -- ------DATE ------ ------------ ---------- <br /> ADDITIONAL COMMENTS <br /> t <br /> - <br /> --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ----------------------�--------------I--- --------------------------------- ---------------------------------------- <br /> ------------------- -------------------------------------------------------------- - <br /> ------------------------------- - --- ----- ---------------------------------------------------------------------------------- ---- - - ---- <br /> c r <br /> Final Inspection by: Date -------------------------------------------- <br /> c <br /> - b l <br /> c - SAN <br /> JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M �I� k <br />