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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ------------- <br /> {Complete in Triplicate) Permit No: <br /> --------------- This Permit Expires I 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-Regoftitions: <br /> JOB ADDRESS/LOCATION _ I__3 S ------ -- ---- -- -----------1----- - --- <br /> �-- �--------------------------------CENSUS TRACT�_�� __. <br /> Owner's Name 1 ----- --- ----- - ----- ------ ---- -- ------------------------ ------- -Phone -------- --------------------------- <br /> Address -----------IF --- -------- City <br /> Contractor's Name -------- 1Y------ -s-e_.License# Phone ------ ----------------------- <br /> Installation will serve: Residence L] Apartment House❑ Commercial :❑Trailer Court '❑ <br /> Motel ❑Other -------------------------------------------- <br /> �fi <br /> Number of living units:------ Number of bedrooms_--_-Garbage Grinder ------------ Lot Size _____T----------------------------------- <br /> Water <br /> _ T_________________________ <br /> Water Supply: Public System and name -------------------- -----_ -x_e__�__�__------------------------------------- --------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ?lay Loam :❑ <br /> Hardpan'[], —Adobe-❑--Fill Material --- ------ If yes,type --•------------------------- <br /> I <br /> (Pl'ot 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_______{'______________ ------------------- Liquid Depth -------_---.--._..._-...-. r <br /> Capacity ------------------- Type ----- -------------- Material---------------------- No. Compartments ----------------- , <br /> Distance to nearest: Well --------------------------------=_Foundation ---------------------- Prop. Line ---------- ,------ <br /> i <br /> LEACHING LINE [ ] No. -of Lines ------------------------ Length of each line--------------------- ------ Total Length <br /> 'D' Box _ Type Filter Material _-_____-'"'Depth Filter Material ____________________________________________ <br /> Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line. ---------.-------------- <br /> SEEPAGE PIT [ ] Depth Diameter ________________ Number __ ------------------------- Rock Filled Yes '❑ No i❑ <br /> Water Table Depth ------------------------------------------------Rock Size -------------------------------- ' <br /> Distance to nearest: Well--------------=--------------------------Foundation -------------------- Prop. Line --------- ........ <br /> i <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ----- <br /> ----------------------------------- --- Date --------._.______________________ ) <br /> Septic Tank (Specify Requirements) ` --------------------------------------�- J-Z-------------------------------------- --------------------------- <br /> P I p Y q 1 ------- -------� r - <br /> Disposal Field [Specify Requirements) ` --------------- <br /> ------------------------------ <br /> -_-____ <br /> ------------------ -= ---'S.--.-..... r te` i <br /> - ----------------------------------------------------------------- <br /> ----------------- ---------------' r <br /> hereby tern that I have 'prepared this application and that the o____________________________________________________ <br /> {Draw existing and-requiied�addition'"on reverse side) <br /> y fy p p pp rk 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 /> --------------- --------- --- n <br /> BY ------- -------------------------- `1�_✓- ---- "-- 'c a Title ----e{'L" --- . <br /> - --- - - - -- - --- - - <br /> ---------------------------------------------------- <br /> (If other than owner) <br /> FOR`DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ----------------------------------------------------- DATE _��� lr� �� --------------- !. <br /> BUILDINGPERMIT ISSUED -------------------------------- ---- ------- ------------------------------- ------------- --------------DATE ------------------------------------------- <br /> ADDITIONAL COMMENTS ------------------------------------- __ <br /> -------------------------------- -- ----------------------------- -------------------------------------------------------------------------------------------------------------------------------------- <br /> ---- -- ----}- --------------------------------------------------------------------------------------------------------------------------------- <br /> ------ ---- - - ------ --- <br /> ------------- ----------------------------------- ------- ------------------------------- <br /> Final Inspection by Date ----•��- -- -- ---------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M, <br />