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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT G <br /> (Complete in Triplicate) Permit No. - ------- <br /> ___ _ __________________-___________-_____________ This Permit Expires 1 Year From Date Issued Date Issued <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 �j----,�-_- -eS--, -, '+,� , .--- ------------------------CENSl15 TRACT __ q__7.-___--_-_-_ <br /> Owner's Name ---- -------ll_ "'±�----------------------------•-- ------------------------- ------------------Phone ------------------------------------ <br /> Address __ ___ City w <br /> C� � <br /> Contractor's Name / «---< -------------------------------------------------------- -------License # ------------------------ Phone -------------------------_-- <br /> Installation will serve: Residence.&Apartment House-[:] Commercial :[]Trailer Court <br /> Motel ❑Other -------------------------------------------- . <br /> Number of living units ______ 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❑ Gay ] Peat❑ Sandy Loam •❑ Clay Loam ❑ <br /> Hardpanfo 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 Size___r___Iq a _S11_'------------- Liquid Depth _ __-..._-__-_____._.. <br /> Capacity ------- TypeIdW. Material-b.-Y14A-4No. Compartments 1'._____•-.._._-__ <br /> i <br /> Distance to nearest: Well __/211!'? --------______________Foundation J-4 Prop. Line __ .._ _._________ <br /> LEACHING LINE [ ] No. of Lines ---__Z----------.----- Length of each line._,1, --------- ------ Total Length _- .f ________________ <br /> 'D' Box 1Ae;_4-&A-Type Filter Material _ _________Depth Filter Material - - <br /> Distance to nearest: Well --- Foundation Foundation - d�______________ Property Line f_ ______--.-_.__ <br /> ,,r `r <br /> SEEPAGE PIT [ J Depth __ ---_____ Diameter __-3_f-____ Number -_-------______.____F-_-. Rock Filled Yes No i❑ <br /> Water Table Depth ----/_----------------------------------Rock Size ---� <br /> r <br /> Distance to nearest: Well '_______________________Foundation _ _------ Prop. Line .......... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------- ----------------------------------- Date _-.__________________.____._______) <br /> SepticTank (Specify Requirements) ----------------------------------------------------------------------------------- ----------------------.-.._--,.--------------------•------ ' <br /> Disposal Field (Specify Requirements) ------------- - - ------------------------------------------•---------._.-.. <br /> ------------------------------------------------------------------------------------------- ----- --- <br /> --------------------------------------------------------------------------- <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that 1 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 becomebje t to Work a 's Compensation laws of California," <br /> Signed .......... --- -- ` ------------------------------ Owner <br /> BY - --- ---- -------- -- - --------------------------- Title - ----- <br /> - ----------------------------------------------------- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ----------------------------------------------------------- DATE -C-------------- <br /> BUILDING PERMIT ISSUED ------------------ --------DATE ----------------------------_--------- <br /> ADDITIONALCOMMENTS ---------------------------------------------------------------------------------------------------------------------------------.:.------------------ <br /> -------------------------------------------------------- ----------------------------------------------- - - ---------------------------------------------------- -- - ---------------- <br /> --------- --------------------------- --- - --- --- ------------ <br /> ------=------- <br /> Final Inspection by: '���'!'-�L l�"� ---------------------------------------------------Date Q--------•------- <br /> t <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />