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FOR OFFICE LISE- APPLICATION FOR SANITATION PERMIT <br /> =------------------------------ Permit No. <br /> ---------------- -- 'Complete in Triplicate) •- <br /> ----------------------------------- <br /> Date Issued <br /> --------------- This Permit Expires 1 Year From bate 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 Co Ordinance 549 a existing Rules and Regulations: <br /> JOB ADDRESS/LO ION ------ --- --- -- ----- - . —-CENSUS TRACT ---------------,-.-------- <br /> - ---------------- --- ----------- -- ------ ---------- --- ---- -------.- one -------------------------------- <br /> Owner's Name _- - - _-- _- - Ph --- <br /> - - r <br /> Address --- c E - - ------ -- -- --- - City --------- ------ <br /> Contractor's Name ------- - - f--- ---- -- ---- ---- ------- - - - - .License # 40>j PI one <br /> Installation will serve: Residence' partment House-E] Commercial:❑Trailer Court IQ <br /> 1 Motel ❑Other -------------------------------------------- <br /> Number of living units:---/------ Number of bedrooms ---''57--Garbage Grinder ---------— Lot Size --_-- -_------ ` <br /> Water Supply: Public System and name --------------------------------------------------------------------------------------- Cla--------•Private <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt E] Clay ❑ Peat ElSandy Loom y Loam ,E] <br /> Hardpan ❑ Adobe ❑ Fill Material ----- ------ If yes,type ---------------------------- <br /> (Plot plan, showing size of lot, location of system in relation for wells, buildings, etc. must be placed on reverse side.) �I <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) V <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size------------------------------------------------ Liquid Depth .---------:--------- <br /> Capacity ------------------- <br /> --------Ca acit - Type -------------------- Material---------------------- No. Compartments <br /> ------------- <br /> � <br /> Distance to nearest: Well _---_--------- ----- p--Foundation -------------- - ----- Pro Line ---------------...-.-- , <br /> I LEACHING LINE. [ ] No. of Lines ------------------------ Length of each line--------_------------------ Total Length .----------------_-_--....__ <br /> 'D' Box ------------ Type Filter Material --------------------Depth Filter Material ----------. <br /> --------------------------------- <br /> 1 Distance to nearest: Well ------------------------ Foundation -------------------- --- Property Line --------- ............. <br /> `/SEEPAGE PIT [ j Depth -------------------- Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No <br /> Water Table`Depth ------------------------' Rock Size <br /> Distance to nearest: Well---------------------------- --------Foundation -------------------- Prop. Line ---------------------- <br /> _�?REPAIR/ADDITION(Prev. Sanitation Permit# --------------------------------`------------i•Date.ti_-_--_`,_--_---_--------------y <br /> Septic Tank (Specify Requirements) --------------------=--------- ----------- ------------------------------------------ ----------- <br /> / 4 <br /> Disposal Field (Specify Requirements) ----------- ----------- - -- ---------------------------- <br /> F ------ ---------- <br /> ---------------------- <br /> ---------------------- <br /> -------------------------- <br /> certify <br /> p p are(Drawexisttingeand required addition on'reverse side) <br /> I herebycertiF that I have re d this application andthatthe 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 sub! Workman's Compens n laws of California." <br /> Signed --- ----- --3- -- = --- Owner .---- <br /> BY --- ` ---- --- ----------------- ---- ------ Title - ---------------------------- ----------------------------------------- <br /> (If other than owner) <br /> I I FOR`DEPART ENT U ONLY <br /> APPLICATION ACCEPTED BY ., ----------- --- DATE .� ' ' <br /> BUILDINGPERMIT ISSUED ------'--------------------------------------------------- ----------------------------------------------DATE ------------------------------------------- <br /> ADDITIONALCOMMENTS -------------------------------------------------------- ------------------------------------------------------------------------- ------------ -------------- <br /> ----------- --------------------------------------- ------------------------------------ ------- ---------------------------------------- ------------ <br /> ------------------------------------------------- : ---------------------- --------------------------------------------------------------------------------------------------------- <br /> ------ ------ <br /> --------------- <br /> Final Inspection by: ry <br /> Date -- --------- <br /> i SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E.'H. 9 .. 1-'68 Rev. 5M <br />