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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT ` <br /> -------- --------- - - - ----- ------ .-..--.- <br /> (Complete in Triplicate) Permit No. 7Z_--.11-3- <br /> ------- ------------------------------------------------- <br /> 1-- ---.--------------------------------------------------------- This Permit Expires 1 Year From Date Issued <br /> 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 C '--M- ,-fL/V-----;7------------------------------------------CENSUS TRACT ------------------------ . <br /> Owner's Namev---------- ---------------------------•------•-------------------------------------------------Phone ------------------------------------ <br /> Address ----I `1City ?;_ ------------- --------------- ----- <br /> Contractor's Name "------��t------------------------License #l2,;3FT'- .-- Phone -------. <br /> Installation will serve: Residence Z Apartment House,[] Commercial ❑Trailer Court ;❑ M <br /> Motel ❑Other -------------------------------------------- <br /> Number of living units:---- .------ Number of bedrooms __�2------Garbage Grinder ZQ---- 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 0 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: f No septic tank or seepage pit permitted if public sewer is available within 200 feet,] <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 [ j No. of Lines ------------------------ Length of each line---------------------------- 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 i❑ <br /> Water Table Depth ------------------------------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well .----_---------------_----------_-----Foundation -------------------- Prop. Line ..........------------ <br /> REPAIR/ADDITION <br /> _------- _REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date -----_---_----___----_---_--------I <br /> Septic Tank (Specify Requirements) ----------------------------------251--------------------------------------------------------------------------------------•-----••-•- <br /> Disposal Field (Specify Requirements) ----- _-- -r--. ---s /__ r--- Py ---------fZ---------•--------------- <br /> ------��-rte--� - --• -- - <br /> ---------- ° hr - ---- --- <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 /> "1 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 ------------[-If--------- ------------------------------------------- ------- ----- - --- <br /> --------- Own <br /> er <br /> £ TitleBY ------ ----------------- <br /> ote -`------- <br /> r than caner) <br /> FO DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY --_,____- _ - DATE - =..-, a`- --_------ <br /> BUILDING PERMIT ISSUED ----- ---------------------------------------DATE ------------- ------------ ---------------- <br /> ADDITIONALCOMMENTS --------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ------------------------------------------------------------ �- -- - - _ :-- ----- ------------ ----------------- <br /> Final Inspection by: ---- ------ ---- ---------- -----------------Date <br /> SAN JOAQUIN I_ AL HEALTH DISTRICT <br /> E. H. 9 1-'6B Rev. 5M <br />