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FOR OFFICE USE: I <br /> APPLICATION FOR SANITATION PERMIT <br /> -------------------•-•-•-- ._....,._._ 70 so3 <br /> Permit.,,No- <br /> (Complete in Triplicate) <br /> --------------------- <br /> ........................................... ..@.r <br /> ------------------------------------------ This Permit Expires 1 Year From Date Issued <br /> Date Issued 5-�© 7 o <br /> Application is hereby made to the San Joaquin Local Health District for a per to construct and install the work herein <br /> described. This application is made in complian with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION .. `-_-D--�J----- --r�"�-----`__-"_"`------------------------------CE=NSUS TRACT --------------A--•-------- <br /> Owner's Name -------- =G --__AD--- --------- ------ ----------------------------------------------------- -- ---------------Phone ----------------- <br /> Address ----[ b------ --- ------- --- -------------- -----•--- City --- <br /> i <br /> Contractor's Name -------- - -------- -- ----- ---- - `-- ------- - -- -------------=------..License # , 71-3 hone ------------------------------ <br /> Installation will serve: Residence Apartment House-[] Commercial ❑Trailer Court <br /> Motel ❑ Other ---------------------------- -------------- <br /> Number of living units:__- .... Number of bedroo s ___5.....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 /> (Piot 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 [ I SEPTIC TANK f ] Size----------------------------------- ------------ Liquid Depth -_____-_ <br /> Capacity ---------------- --- Type -------------------- Material.--------------------- No. Compartments ------------=.......... <br /> Distance to nearest: Well ------------------------------------Foundation ----------------------.Prop. Line ---------.-_. ...... <br /> LEACHING LINE [ j No. of Lines ------------------------ Length of eachline---------------------------- 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 :Q <br /> Water Table Depth --------------------------- ----------- --------Rock Size -------------------------------- <br /> Distance to nearest: Well ----------------------------------------Foundation ----------- -------- Prop. Line ----------_____-_._-- <br /> REPAIR/ADDITION{Prey. Sanitation Permit# ..._.....----------------------------------- bate ------.._____-.._..---:.--.-.---__l <br /> Septic Tank (Specify Requirements) --------------------- -------- ----------------------------------------------------I--------------------------- <br /> Disposal Field (Specify Requirements) -- +- ---___ ---��" -.---- I ��--------- <br /> -----���--- - - ------ --------- ------------------------------------------------------------------------------------------- ------------------------- <br /> - -------------------- --------------------------------------------------------------------------------- ---------- <br /> {Draw existing and required addition on reverse side) 11._f_ <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 Distrid. Home owner of licen- <br /> sed agents signature certifies the following: 1. <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 Workman's Compensation laws of California." <br /> Signed ------------------ - ---------------- - - - -- - - Owner � ------------------------------- <br /> --- <br /> - ----------- ----- <br /> By --------- - ------ - --------- <br /> -- ---------- <br /> (if <br /> ------- Title ------ - - <br /> (If of er than owner} <br /> FO DEP MENT USE ONLY <br /> APPLICATION ACCEPTED s.e-C ------=-- - - DATE -----�----_-�z------------------- <br /> ------------------------------------------------------ <br /> BUILDING PERMIT ISSUED ------------- <br /> ----- - -- <br /> ---------- ---------------------------------------------------------------------DATE -------_--------a-----------------' <br /> ---------- <br /> ADDITIONAL COMMENTS ---------_________________ 4 ------------------------ - - -- - <br /> ' <br /> - -- --------------- - -------- ---a__C---------------------------------------------------------------------------FinalInspectio Y - - � --------------------------------------------------Date -------------------------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'b8 Rev. 5M• V <br />