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FOR OFFICE USE. - <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit No: _171-:�_------ <br /> --------------------------------------------------______ This Permit Expires T Year From Date Issued Date Issued <br /> C)23 <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 kles and Regulations: <br /> Olt <br /> '. <br /> JOB`ADDRESS/LOCAT N _ _-sr -_- NSUS TRACT , <br /> -------------'--- ----------------Phone <br /> .-._Owner's Name <br /> Address - --� �� -- � ----------------------- --•-- City -�------ ` <br /> ffhk---A f <br /> .----------- <br /> Contractor's <br /> Name ------------------------------------------------------------------License # ------- ----------------- Phone ------------------ <br /> Installation <br /> ----------------Installation will serve: Residence ❑Apartment House-C] Commercial ❑Trailer Court <br /> Motel ❑ Other - ------- -------- <br /> Number of living units_____________ Number of bedrooms ____________Garbage Grinder __--.__-__-- Lot Size _______________ar _______ <br /> -------------------------- <br /> WaterSupply: Public System and name ----------------------•----------------------------------------------------------------------------------------Private,] <br /> 7 <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam r�12 Clay-Loam ❑ <br /> Hardpan ❑ Adobe ❑ 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.) U1 <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted it public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK Size � ` �-------------------- Liquid Depth1 <br /> Capacity 1 _ ------- Type Material_ __________ No. Compartments _.._.. . . <br /> Distance to nearest: Well ----------------------Foundation 1 ---------------- Prop. Line ._..5./:?�__......_ <br /> LEACHING LINE No. of Lines -- ---------- -------- Length of each line_______j0jP 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 0 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 /> DisposalField (Specify Requirements) -------------- ------------------------------------------------------------------------------------ --------------------------------- <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 . sad'to Work �s, ensation laws of California." <br /> Signed ____::- ::---------------- Owner <br /> By '- 1 - -- - ------------------------------- -Title ---------------- <br /> ------------------------------------------------------- <br /> { other than owner' <br /> -FOR .DEPARTMENT USE ONLY p <br /> APPLICATION ACCEPTED BY --------------------•--------------------------------------- DATE --- -------_--------- <br /> BUILDING PERMIT ISSUED ------------------------------------- - -------DATE ------------------------------------------- <br /> - --------------------------------------------------- -- <br /> ADDITIONALCOMMENTS --- ------------------------------------------------------------------------------------------------------------------------------ <br /> -------------------------- - ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> , <br /> ----------------------------------- <br /> ------------------------------------------------------------------ --------------------------------------------------------- -- <br /> ---------- <br /> ----------- ---- <br /> - ---------------- <br /> ------- <br /> =-------------------------------------------------------------------- ------ j <br /> Final Inspection by -----------------------------------------------------------------------------Date' '% " ° -- - ---- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />