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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> .r <br /> (Complete in Triplicate) Permit No. _ -__- -___ <br /> ----------•---------------------------------------------- <br /> --------- ---------------------- -----------------?------- <br /> -----------------=-------- -----------------------------------------`-----_-__-____-- This Permit Expires 1 Year From Date Issued <br /> Date Issued121 <br /> 0a5' <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and ins tafE the work herein <br /> described. T 's application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESO rt <br /> S/LOCATI ` ---_.. 4 1 DO_ `� ajc- -------- '-94.-CENSUS TRACT ------------------------- <br /> 0 Name _ .__- ,w <br /> r = - --------Phone ------ ----------------------------- <br /> Address ---- " City <br /> ----------------------- ------- <br /> Contractor's Name _lv� _.---- ------ ----- _ --_ License # �_. - <br /> hone <br /> Installation will serve: Resi ence Apartment House❑ Commercial ❑Trailer Court ❑ <br /> Motel ❑ Other <br /> Number of living units':---- --- Number of bedrooms -- ___-:_Garbage_Grinder. ------ Lot Size --------------------------------- <br /> Water <br /> _--__ _-_--_---------------Water Supply: Public System and name ------------------------------------------------- -------------------------Private <br /> Character of soil to a depth of 3 feet: Sand';"�Aclobe [] <br /> ilt❑ Clay ❑ Peat EJ Sandy Loam ❑ Clay Loam;❑ <br /> W' <br /> Hardpan Fill Material ------------ If yes, type ---------------------------- <br /> (Plot <br /> ----- ------------_-----(Plot plan, showing size of lot, location of system 'in relation to- wells, buildings, etc. must be placed on reverse side.) r <br /> NEW INSTALLATION- (No septic tank or seepage pit permitted if public sewer is available within 204 feet,) <br /> k <br /> PACKAGE TREATMENT SEPTIC TANK,[ ] size------------------------------------------------- Liquid Depth -------------------------- <br /> Capacity -------------------- Type -------------------- Material---------------------- No. Compartments --------------------- <br /> Distance <br /> --------- --Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop..Line ----------------._.--- <br /> LEACHING LINE [ ] No. of Lines ------------------------ Length of each line----------------------------- Total Length ---_--------- _ -__ -------- <br /> Type Filter Material -_-_--_ - <br /> - ------.Depth Filter Material a <br /> 'D' Box ___--__----- T e <br /> -------------------------------------------- <br /> Distance to nearest: Well ---------_------i--_:__ Foundation ------------------------ Property line- __.-__.-----__- <br /> SEEPAGE PIT [ j Depth -------------------- Diameter __-___.-------_ Number --------------------- Rock Filled Yes ❑ No .C] <br /> Water Table Depth ------------------------------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well ___------------------------------ --Foundation ---------------.---- Prop. Line --_-_---_-__- ........ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -•----------------------------------------- Date --_----_----_---------------------1 <br /> Septic Tank (Specify Requirements) ---------------- -------------------------------- - <br /> - ��y--- - -- ------------ - ------ - ---- <br /> Disposal Field (Specify Requirements) sc. ------------------------ <br /> F <br /> r f s ---- <br /> Q - -- - -----�'°-----1----- - f/ 3 <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 i <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 War n's Compensation laws of California." <br /> Signed ----------------------- ------- -- - ----- Owner <br /> -------------- -- <br /> - <br /> - ---- ------ <br /> BY - _ + Title -- - �-U <br /> (If other than owner) (] <br /> -FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY _.-- ..... _ _ ----- -- ---------- `p gg <br /> ---------- -- --------------------------- - -------------- DATE -�--- -�-l- "7------------------ <br /> BUILDING PERMIT ISSUED ----------------------------------------------------------------------------------------------------------DATE -------�- <br /> ------------------------------------- <br /> ADDITIONAL COMMENTS ---- - -----------------------------------------------------------------------------------------------------------------=----------•----•- ----- <br /> ------------------------------------ ----- ----- v------ - ---------------------------------------------------------------------------------- <br /> Fina Inspection by: --------- ------------------------------------------ ------------------- <br /> -Date <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />