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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ------ ------------------ ------ -- Permit No. <br /> (Complete in Triplicate) - <br /> ------- -------------------- --------------------------- 3j 7,V <br /> ----- --- ---------- --------------- This Permit Expires 1 Year From Date Issued Date Issued _/_.__---- <br /> �_____. <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. 5A9 and existing Rules and Regulations: <br /> JO ADDRE1S�-��SS/LOCATIO� _ ----------CENSUS TRACT ------------------------ <br /> 4 JOB DDRE ��_--__.__-__-1Y-�_'W____ __�v ----------- <br /> Owner's Name -- - -P . -------Phone.9 -'� Z .- .. <br /> Address -------------- ---------------------------- ----------------- <br /> -- <br /> Name ------ ----------------- --------------- ------ ---- o- -t—--------------------.License # --------- Phone _ _6 , b ..... <br /> Installation will serve: Residence ❑Apartment House❑ Commercial [-]Trailer Court ;❑ <br /> Motel E]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:❑ 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: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT ( ] SEPTIC TANK:[ ] Size------------------------------------------------ Liquid Depth ------------------..-.---- Ilk . <br /> Capacity -------------------- Type -------------------- Material--------------- ------ No. Compartments <br /> f� <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 ______________ ._.._.., V) <br /> SEEPAGE PIT [ ] Depth Diameter ______________ ❑ No d <br /> Number ------------- -------------- Rock Filled Yes <br /> Water Table Depth ------------------------------------------------Rock Size -------------------------------- <br /> 4 Distance to nearest: Well _______________________________________Foundation -------------------- Prop. Line ---------------_----- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------} <br /> SepticTank (Specify Requirements) -------------------------- -------------------------------------------------•------------------------.._-.._--------------------------- <br /> Diosal Field (Specify Requirements) ------------------------------••----- ---- ------------------------------------------------------------------------- --------------- <br /> ---- ------------- - - �------ P- <br /> F - - -tea ,_� A&A----- - _ ----------- <br /> (Draw existing and required addition on reverse se 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 ----------- -------------- --------- --- --- Owner <br /> BY <br /> ----- Title ------ ---- -- <br /> (I othe an owner) <br /> FOR DEPARTMENT U E NLY <br /> APPLICATION ACCEPTED BY ---- = = J DATE ------q7. ------------ <br /> BUILDING PERMIT ISSUED -------- DATE <br /> ADDITIONAL COMMENTS ------------•---------------------------------------------------------------------=--------- ----------------- <br /> ---------------------------------------------:------------------------------------------------------------------------------------------------------------------------------------------------------------ <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> - ------------------------------------------------------------------------------------------------------------------------ ^ ---------- <br /> Final Inspection by ---- ------------------- -------- -------------- <br /> -------------------------------------------- -- --- � . lG _ <br /> _.__ ____Date -_-------------- <br /> SAN JOAQUIN LOCAL HEALT �TRICT <br /> E. H. 9 1-'68 Rev. 5M <br />