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FOR OFFICE USE: �� <br /> ! APPLICATION FOR SANITATION PERMIT <br /> ------------- <br /> (Complete in Triplicate) Permit No. <br /> ---------=-- -------------------------------------------- c3 <br /> Date issued <br /> ------------------------------------ _ <br /> - --_---------- This Permit Expires 1 Year From Date Issued <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 />{ p CENSUS TRACT I---------------- <br /> JOB ADDRESS/LOCATIO � _ _/._ ___, ___ - -------- ---- - <br /> Owner's Name ----- lt.�------fc�---�`-�--- --- `f--------------------------------- ---Phone 3-6---- �3���-- . <br /> Address ----/-�--0�_ ------- <br /> Contractor's <br /> ----- City '�� <br /> Contractor's Name _ _ (( --------- ----------Licens ----- Phone ------------------------------ <br /> - e # <br /> ❑ p ❑ ❑ ❑ <br /> P <br /> Installation will serve: Residence Apartment House- Commercial Trailer Court <br /> Motel ❑Other -------------------------------------------- <br /> Number of living units------------- Number of bedrooms ___-___-____Garbage Grinder ____________ Lot Size -------------------------------------------- <br /> Wafter Supply: Public System and name --------------------------------------------------------------------•------------------------------------------Private E]i Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ 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 --------:-------------------- <br /> Capacity ---------- Type ____________________ Material---------------------- No. Compartments ------------- <br /> FDistance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ---------- W <br /> LEACHING LINE [ ] No. of Lines ----. _________ Length of each line---------------------------- Total Length _-_.--.___--_-____ ......... <br /> 'D' Box ------------ Type Filter Material --------------------Depth Filter Material --------------------.---------------_----- .V <br /> Distance to nearest: Well _______________________ Foundation ------------------------ Property Line. --------------------- <br /> SEEPAGE <br /> __SEEPAGE PIT [ ] Depth ________________ Diameter ---------------- Number ---------------------------- Rock Filled Yes [] No I❑ <br /> i <br /> Water Table Depth ------------------------------------------------Rock Size ---------------------------•---- <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ---------------------- <br /> i t . <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------- ----------------------------------- <br /> [ y <br /> Date <br /> e ------^-"-.-------------------------- <br /> P (Specify Requirements) ------------------------------------------ -- --- r---------------- ------ ----- ----1- <br /> ---------- -----'-- <br /> ---- ----- <br /> �_ 41.._,Disposal Field (SpecifyRequirements)rements) ---- -� -------- --------------------------------------------------w----------•---•------®--- <br /> ----- <br /> ---- <br /> ---- ------------------ ---------------I ------------ ------------------------------ -------------------------------------------------------------------------------------------- <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: w <br /> "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner <br /> as to be a ubject to Wo kman's Canpensatian I ws of California." <br /> - �f3+- ------------- --•--- Owner <br /> Signed ._ <br /> BY -------------------------------- ---- <br /> --- ------------------------------------------------------------ Title ------_------------- ------------------------------------------------- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ------ -- -- - ------------------ -------------------------------------- DATE _37,7 t,7'-/.a-- ------------- <br /> BUILDING PERMIT ISSUED ----------- <br /> -------- L <br /> -----------------------------------------------------------------------------------------------DATE ----' ------------------------------------- <br /> ADDITIONALCOMMENTS -----------r- ----------------------------------------------------------------------------------------------------------- ------- -------------I------------- <br /> i <br /> I <br /> ------------------------------------------ ----- ----------------------------------------------------------------------------------------------------- <br /> k ----------------------------------- - ------------------------------ - - ----ry -- <br /> Final inspection bY- - -- -- ---- ---- ---- - --------------------------•--•------------------------------------------- - Date ��1 f <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ' E. H. 9 1-'68 Rev. 5M ,, <br />