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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ------------------------------- <br /> (Complete in Triplicate) Permit <br /> - -- ----------------------------------- <br /> ------ This Permit Expires 1 Year From Date Issued Date Issued _S._ ,//' <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 Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION .- S - � - ! r---CENSUS TRACT -------------------------- <br /> Owner's Name 1_7 a-1---- - --- ----- -- Phone ------------- ---------------------- <br /> Address ---- ---- a -- - � City - <br /> ----- <br /> - ----------- ffPhone <br /> SContractor's Name ----- ------ - - ------ --- -- -----.License # _f� <br /> Installation will serve: Residence Apartment House 0 Commercial❑Trailer Court !❑ <br /> Motel ❑Other ------------------'------------------------- / <br /> Number of living units:----- ____ Number of bedrooms ------Garbage Grinder ---r/-__ Lot Size --Q __________________ <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 /> a <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) / <br /> PACKAGE TREATMENT (� SEPTIC TANK [ ] W Size_T <br /> _ __ ___ _ __ ___ ___________.-- Liquid Depth __� _ <br /> _ _____-__,_____ W <br /> Capacity _1- - _4__ ___ Type ------ . Material--- _.--- No. Compartments ---1;1�_______.___ <br /> s 9pf / <br /> Distance to neare : Well :Foundation -----1__C_�._____.._-- prop. Line _,a--------------- <br /> LEACHING LINE [.� No. of Lines -----5..�______ <br /> Length of each line___ 'n___________________ Total Length _a*___._.._.__.____ <br /> �o I ri <br /> 'D' Box -__�l Type Filter Material f____ ±+KI---Depth Filter Material ____If___________________________________ <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 ---------------------. -----_-----) <br /> Septic Tank (Specify Requirements) ----==---------------------------------------------------------`-- ='----:-------------------------------------•'-- <br /> Disposal, Field (Specify Requirements)-------------------------------- --------------------------------------- --- =->:-----------------------------•--- ------ <br /> --------------------- ------- --- --- -----------------------------------------------------------------------I-------------------- ------------------------------------------------------------------------ <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 /> BYTitle - ----------------------------------------- <br /> (If other than owner! <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -------- -- ------------- ----------------- DATE -------------- <br /> BUILDING PERMIT ISSUED --------------------------------------------- - ---------------DATE ----------------------------------------- <br /> ADDITIONALCOMMENTS -------------------------------------- -------------------------------------------------------------------------------------------=------------- ------------- <br /> --------------------------------------------- ----------------------------------------------------------------------------------------------------- ---------------------------- ---- ------------ <br /> R <br /> __________________________________ ________________------------------ --- <br /> ------------------------------- <br /> Final Inspection by: ---------------------------------------------Date <br /> --------- <br /> ---------- <br /> SAN <br /> JOAQUIN LOCAL. HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />