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IR <br /> OFF.ICJ USE: �„ 4. . t APPLICATION FOR SANITATION PERMIT <br /> l= - <br /> ------ ----- ---------I--------- Permit No: -------------- <br /> . (Complete in Triplicate) <br /> -----y 7� <br /> Date Issued --------- -- -- <br /> ° This Permit Expires 1 Year From Date Issued <br /> 3' 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. 50 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION _. . . .� --- � <br /> l�/CENSUS TRACT -------------------------- <br /> ne -- <br /> Owner's Name Ci-----------_ �, Pho - - ---------- i <br /> ,1 / -------- �G_.✓ <br /> �--- --- ------------------ <br /> A A . <br /> L -------------- --- ---_ <br /> ----------------------- <br /> Address ----------- r. l����--- ------ -- - f1' -- - --� ------- - - <br /> �_ Phone <br /> Contrac#or's Name _ --- ----- - <br /> License # <br /> Installation will serve: Residence Apartment House❑ Commercial:❑Trailer Court i0 <br /> " Motel ❑ Other -------------- ---------------------------- <br /> Number of living units:___ ----- Number of bedrooms -- -- ---Garbage Grinder /. - Lot Size - +e ms �f-- ------ <br /> Wafter Supply: Public System and name ------------------ ---• - Private <br /> Peat❑ Sand Loam Clay Loam <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Y ❑ <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'[ I Size------------------------------------------- <br /> I <br /> Liquid Depth -----------------•----•--- <br /> Ca acit T e __-- Material---------------------- No. Compartments ----------------•_---- <br /> P Y ->I------------ -- yP <br /> Distance to nearest: Well ------------------------------------Foundation --------- ------------.Prop. Line ---------- _-------- <br /> - Total Len th <br /> LEACHING LINE [ } No. of .Lines ------------------ ---- Length of each line_____-__._.. ----------- g :----------•----••----...__. <br /> 'D' Box ---- ------ Type Filter Material --------------------Depth Filter Material ------ ------------------------­------------- <br /> Distance <br /> ---------• - -•-----•- <br /> Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line. --------------------•--- <br /> SEEPAGE PIT [ ] Depth -----'-------------- Diameter ----------_----- Number ---------------------- ----- Rock Filled Yes '[] No I❑ <br /> i <br /> WaterTable Depth ------------------------------------------------Rock Size ----- -------------------------- <br /> I ---Foundation -------------------- Prop. Line -.--------- ------- <br /> Distance to nearest: Well ----------------------------------- - -�- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------- ---------- -- Dd#e } <br /> ------------------------------------ <br /> - --- <br /> Se tic Tank (Specify Requirements) -------------- - <br /> f <br /> A--- -------- <br /> ------------ <br /> Fiell ------------ <br /> Disposacify Re u�r ------------------------ <br /> ------------------------------ <br /> ---------- <br /> --------------------------------------------------------------------------------- ---------- <br /> ---------- -- <br /> ------I--------------- ----------------------------- <br /> --------- <br /> -- ---------- I (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 /> f Signed ----------- ---------- ---------- - ---------------------------------------------- <br /> ___-_ Owner _ - •�. . <br /> ------- <br /> ------------ Title --- ---------- ----------- <br /> f of er t an owner) <br /> + FOR DEPARTMENT USE ONLY <br /> �L ' `7 5) <br /> APPLICATION ACCEPTED BY : _�. L�- a-1/ ---=----------•---------------------------------------- •DATE -- ------ T ---- <br /> BUILDINGPERMIT ISSUED --------------------------- _------------------------- - --------------------DATE <br /> ADDITIONALCOMMENTS ------------ -- ----------------------------------------- --------- ---------------- -------------_---- <br /> i r <br /> i -- ---- ---------------------------------- ----------- --------- <br /> ------------------------------------------------ - <br /> ----- <br /> Final Inspection by. { --------------------- --`--------------- <br /> - - ------ - - - <br /> SAN : AQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />