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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> --------------------------- <br /> - --------- - -•-------------------- (Complete in Triplicate) Permit <br /> ---------------------------------------------------------- <br /> This Permit Expires 1 Year From Date Issued Date Issued __Z-7r:_67_ <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 O finance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION -- - - - .__._�__ '�_- <br /> -- - ---- --- -- CENSUS TRACT ------------ ---- -------- <br /> Owner's Name - --------- -------- -----------------•------------------------------- - --------- -----Phone --------------------------•----•---- <br /> AddressQ. -� City -----------------------------•----- <br /> r <br /> Contractor's Name t License Phone <br /> Installation will serve: 3, Residence ❑Apartment House❑ Commercial❑Trailer Court <br /> Motel ❑Other ---------------------------- ----------------- <br /> Number of living units:---11_--_ -�1- <br /> 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 ❑ Peat❑ Sandy Loam ❑ Clay Loam <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'S ] Size----------------------------------- ------------ Liquid Depth --------------------------- �Ur <br /> Capacity -------------------- Type -------------------- Material-------- No. Compartments t' <br /> Distance to nearest: Well ------------------------------------Foundation --------------------- Prop. Line ---._--_-_----_------- <br /> LEACHING LINE [ ] No. of Lines ----------------- ------ Length of each line---------------------------- Total Length ------.--------___-_----___- •�/ <br /> f '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 ❑ <br /> Water Table Depth ------------------------------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ---•------------.----- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ---------------- ------------------ Date ----------------------------------11 <br /> Septic Tank (Specify Requirements) ------------------------------------------------------------------ ---------------------------z---------------------------- <br /> Disposal Field (Specify Re uirements) ..- -_- _ __ -` � xra- <br /> ------------------- <br /> i V <br /> /---------------- ----- �2. --A IV_,4V1 ---`--- i <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, 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 /> BY -----------L;4���------ - ------ -- T <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY . ----------------------------------------------------- DATE ---------------- ------------------- <br /> BUILDING PERMIT ISSUED --- -------------- -- - - ----DATE ------------- ------------------- --------- <br /> ._ . . .. -._. _.__.. _. _.... .- <br /> _ <br /> ADDITIONALCOMMENTS ----------------------------------------------------------------------------------------------------------------------------------------------•---------------- <br /> --------- -- ----- ------- --------------------------------------------------------------------------------------------- ------------------------------------------------------------------ ---- <br /> ------ ---------------- <br /> I Rry <br /> Final Inspection by: Dat - --------- - -------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />