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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> Permit No: <br /> {Complete in Triplicate} <br /> �-3."30------. <br /> --------------------_---------_-------------------------- � This Permit Expires 1 Year From Date issued <br /> Date Issued � ._y,1z_3. <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 omade in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOC TION .�_9--6A_� ___ ___. __ _� , Iar— '�_ ENSUS TRACT .......................... <br /> Owner's NcjrQe — � - -c.-c--------------Phone ------------------------------------ <br /> Address .. i_.�_t--- - Cityfs ,r, --------------------------------------------- <br /> 4 <br /> -------- ----- // <br /> Contractor's Name - F r License # .L_ _3 Phone ------ ----------- <br /> Installation will serve: Residence ❑ Apartment House❑ COnam.PrcialOTrailer Court 0 <br /> Motel ❑ Other ___ a•4•e?__ ___________________ <br /> f <br /> Number of living units:_____�_ Number of bedrooms __-_ .Garbage Grinder _7_____ 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 .e 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 f ] SEPTIC TANK'[ ] Size------------------------------------------------ Liquid Depth _------------------------- <br /> Capacity --------- --- ------ Type -------------------- Material------------- -------- No. Compartments ---------............. <br /> 1 <br /> Distance to nearest: Well ____________________________________Foundation ---------------------- Prop. Line ...................... 9 <br /> LEACHING LINE [ ] No. of Lines --------- ------ ------- Length of each line---------------------------- Total Length ----------- --------- ...... <br /> 'D' Box ------------ Type Filter Material --------------------Depth Filter Material ------------------------------------------- 0 <br /> Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line -------------------- --- Z <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ________________ Number ---------------------------- Rock Filled Yes Q No C] <br /> Water Table Depth ------------------------------------------------Rock Size --------------------------------- -C <br /> Distance to nearest: Well ________________________________________Foundation --------- ---------- Prop. Line _-_.____..____.___..__ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ------------------ Date __-__.-___________________________1 1 <br /> SepticTank (Specify Requirements) --------------------------------------------------------•-----------------------------------------------------•- ------------- --- --------- <br /> Disposal Field (Specify Requirements) ___ s ___• l�• 4�,- -- ________ r ______ ,.,.��_- V <br /> ------------- -------- ' .�Y 1 f_ ----- -- --------------------------------------- <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. 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 ---------------- ---------- ----- '�r -- ----- Owner +" <br /> BY - - ----------------------------- <br /> �Ci�_ �/�- - Title <br /> ----- ---- -- <br /> (if other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -- ---.-)q--------------------------------------------------- <br /> ---- DATE --- - ~72------ <br /> BUILDING PERMIT ISSUED ---------------------------- -------------- ---------- -------DATE ----------------- ------------------------- <br /> ADDITIONALCOMMENTS ------------------------------------------------------------------------------ ---------------------------------------- -------------------------------------- <br /> --------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------- <br /> ---------------------------------------- <br /> ----------------------------- <br /> --- -- ------ --- ---------------------------------------------------------------------- -- <br /> -- <br /> ------- <br /> Final Inspection by: . --------------------------------------------------Date - -- ��c <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />