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-» FOR,,-OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ----------------------- <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 !- 7 ........ "--- 1 ---------------------------------------------------CENSUS TRACT---------------- - --------- <br /> Owner's Name .-- ' ------- &---------------------------------- -- <br /> Address ----------------------------=-- --- City <br /> Contrar_tor's NameV <br /> ----------------------- # - - 3--- Phone y <br /> Installation will serve: Residence ❑ Apartment House❑ Commercial ❑Trailer Court ❑ <br /> MoteloOther ______________ <br /> Number of living units:....1------ Number of bedrooms __arbage Grinder ______ __ Lot Size _.1.__ '- ----___ __________ <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 ❑ Adobex Fill Material ------------ If yes,type --------------------------- <br /> W <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_______________________________________________ Liquid Depth ___._______________-_._.. <br /> Capacity --------- ---------- Type ----- -------------- Material---------------------- No. Compartments ------ ------•- -----• V <br /> Distance to nearest: Well ____________________________________Foundation ---------------------- Prop. Line ________________-_____ <br /> LEACHING LINE [ ] 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 0 ' <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 /> Dis osal Field (Specify Requirements) ___________ 1_67-;3?Al-l-_______ _____- <br /> ] ---------- .�L.r�---------o�--------- ------.... -----.4l,eVoe----------------------------------------------- <br /> ------------------------------------------------------------------------------- ----------- <br /> - -- -------------------- <br /> --------------------------------------------------- ------- -- <br /> (Draw existing <br /> 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 sub'ect to ork n's Compensation laws of California." <br /> Signed ----------- ----------- --- -------------------------------------------- Owner <br /> --------- - -- <br /> BY ---C-------- <br /> ---r----- -------- - ----- Title <br /> -------------------------------------------------------------- <br /> -------- - -- ---- --- - - - - - - - <br /> [If of tan owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY --------------------------------------' DATE __. -�- a <br /> BUILDING PERMIT ISSUED ----- ----------------- <br /> ------------------------------------ <br /> --------------------------------------DATE ------------------------------------------- <br /> ADDITIONALCOMMENTS ------------- --------------------------------------------------- ------------------------------------------------------------- --------------•---------------- <br /> --------------------------------------------------------------------------------------------------------------------- ---------- ------------------------------------------------------------- <br /> ------------------------------------------ <br /> ---------------------------------------------------------------- - - ------- -- - ---- <br /> ------ <br /> FinalInspect-on bY- -- - ---- -- ---------------------------------------•---------------------------------------.Date _.._. ------ --------c�----------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M C <br />