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FOR OFFICE USE: <br /> t.3 0 ..— APPLICATION FOR SANITATION PERMIT <br /> ------ Permit No: <br /> (Complete in Triplicate) <br /> ---------------------------------------------------------- <br /> ------- -- <br /> ------...--.-.-_------------------------------:--------------- This Permit Expires 1 Year From Date Issued Date Issued ....q" .7 Z <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 w�ithh CCouun'tyy Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATI N _.__._/.... ------- <br /> fv[_`ul xet cj"J________ <br /> -------------------------CENSUS TRACT <br /> Owner's Name -- - ------------ -------- ------- --_---------------------Phone L/7 _ _N........... <br /> Address —' ---5--f------------------ City <br /> - <br /> Contractor's Name .--...-- --- - ----- .. © y�------------- - ------.License # ----- Phone <br /> Installation will serve: Residence�44artment Housef❑ Commercial :❑Trailer Court i❑ <br /> MotelOther --- ----------------------------- --------- <br /> f <br /> Number of living units:.---!-_----- Number of,bedrooms -__ ._..Garbage Grinder ------------ Lot Size ---��.- .. 7 ............. <br /> Water Supply: Public System and name -_ '_�±-.....-._-�.-._._. ____' Private <br /> a� } <br /> Character of soil to a depth of 3 feet: Sand'[]: Silt❑ Clay ❑ Peat❑ Sandy Loam 0 Clay Loam.0 <br /> Hardpan ❑=7 AdolSe []Fill Material ------------ If yes,type ---------------------------- <br /> (Plot <br /> --------------------- ---(Plot plan, showing size of lot, location of system in 'relation to wells, buildings, .etc. must be placed on reverse side.) ` n <br /> NEW INSTALLATION: (No septic tank or seepage,.pit'permitted if public sewer is available within 200 feet,) Vl <br /> PACKAGE TREATMENT { ] SEPTIC TANK.X } 4 S' e___.-.A:�----_ ------------------- Liquid Depth <br /> Capacityf ----. Type`-_ .- Material--C --- No. Compartments �................ <br /> - 4 . 's 1 ] f i /4- <br /> Distance to nearest: Wel . ------------------Foundation ---/0._.._.--_-_ Prop. Line __dam.-...._._...... <br /> LEACHING LINE No. -of Lines .... -------------- Length of each line-------_ __�--------- Total Length 1�.�......_._.. - <br /> <� <br /> 'D' Box -.__._✓Type Filter ,Material _90-CZ Filter Material _...f...... .............................. <br /> Distance to nearest: Well -`-- ��_"�"_ � Foundation ------------------------ Property Line -__._.._......_._.._-._. <br /> f <br /> SEEPAGE PIT [ ] Depth ------------- Diameter ---------------- Number l.-.---------_----___.-...-'_ 'Rock Filled Yes ❑ No <br /> Water Table Depth -----------------------------------------------Rock Size --------------- t.' : <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line .-----.._-_._____-_-__ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# --------------- - -!-_- :=--'-____----.- Date ----------------------`-----------I <br /> Septic Tank (Specify Requirements) ------------------ ---------}------------------------------------- ---------------------- .•-------------•------------- <br /> Disposal Field (Specify Requirements) <br /> ^_ <br /> . r <br /> ---- ----------------------------------------------------- --- ---------------------------------------------- - - <br /> "i <br /> t - <br /> ---------------------------------•--------- - ------- ---------------------------------------------------------- <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 /> BY 1---�� '3 Tit•!e�- <br /> - <br /> (If of r than owner) <br /> OR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY --- - -- ------ - -- ----- ----- ---------------------"----------------- --------- DATE -- <br /> BUILDING PERMIT ISSUED ------------------------- -------------=--------------DATE ------------------------------ ----------- <br /> ADDITIONALCOMMENTS - -------- ----------------------------------------------------------------------------------------- <br /> ----------------------------------------------------- --------------------------------------------------------------------------------- -------------------------------------------------- <br /> ---------------- ----- <br /> ---- <br /> ----------------- ------------------------------ ---- <br /> -- <br /> --------------------- - ------------------- <br /> ------------- ---- - -- - -- --- - ------------------------------------- <br /> -Fina] Inspection by: - ------- <br /> SAN J` AAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />