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FOR'CiFFICE USE: <br /> .Ty <br /> APPLICATION FOR SANITATION PERMIT > <br /> ��---- ---------------------------------- (Complete in Triplicate) Permit No: <br /> --------- ---- <br /> Date Issued __ 7Z_. <br /> --------------------------------------------------------- This Permit Expires 1 Year From Date Issued '7. w <br /> Application is hereby made to the San Joaquin Local Health District for a per 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 /> c <br /> JOB ADDRESS/LOCATION ---- -------CENSUS TRACT ----------------••--------. <br /> Owner's Name -------------- Ci"`i ----------- <br /> - _ - Phone <br /> Address = -------- City - - <br /> Contractor's Name ----------------------- r----------- am—t v ----License #jell------- Phone d EGD <br /> Installation will serve: Residence MApartment House❑ Commercial:❑Trallei_Court i❑ <br /> Motel ❑ Other -------------------------------------------- r ' <br /> Number of living units:.... Number of bedrooms ________Garbage Grinder ---_-/ Lo Size _ r _________________ <br /> Water Supply: Public System and name ------------ --------------.----------------------------------Y__ --------------.Private ❑ <br /> Character of soil to a depth of 3 feet: Sand'o Silt❑ Clay ❑ Peat❑ Sandy Loam -❑ Clay.Loam ,E] <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.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) i <br /> PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] Size------------------------------------------------- Liquid Depth -----------_-------------. �9 r <br /> Capacity -------------------- Type -------------------- Material---------------------- No. Compartments ---------------------- <br /> Distance to nearest: Well __________________________________Foundation ---__--------------------- Prop. Line ----------------------- <br /> LEACHING <br /> ___----- ---:-. __LEACHING LINE: [ ] No. of Lines ________________________ Length of each line------------------------- Total Length _---__-____.______________-. k <br /> 'D' Box ----- ------ Type Filter Material ___-_- _______Depth Filter Material ______________________ $ <br /> Distance -to nearest: Well ------------------------ Foundation ------------------------ Property Line ______--._--_-__-__-__ , <br /> SEEPAGE PIT [ ] Depth ____________________ Diameter ---------------- ------ --------------------- Rock Filled Yes ❑ No ❑ <br /> Water Table Depth ------------------------------------------------Rock Size'------------------- <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ---------------------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ____________________________________________ Date -_____-_____-____________________) t <br /> Septic Tank (Specify Requirements) ------------------------------------- ----__-___-___ __ <br /> Disposal Field (Specify Requirements) --- --------------------------------------------------- <br /> Disposal <br /> ---` --- -----------------•--------------- <br /> f! Z - ----- ------------------- <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, II shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed ------------------------------- ----- ------ Owner <br /> 4A` Title ----------- ----------------------------------------- <br /> (lfother t a owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY __Q_,,_ -------------------------------------------- DATE - ------------------ <br /> ------ -------------- / -------- ---------------------- ------------- <br /> -DATE - ----- ----------------------------- <br /> BUILDING <br /> PERMIT ISSUED . <br /> ADDITIONALCOMMENTS -------------------------------------------------------------------------------------------- ----------------------------------------------------------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> -------------------------------------------------------------------- ---- --------- <br /> -------------------------------------------- <br /> ----------------------------------------------------------- - ---- ---- --- --- ---------- <br /> Final Inspection b _ __ Date .� --_.___. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT J; <br /> E. H. 9 1-'68 Rev. 5M �1 <br />