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FOR OFFICE USE- APPLICATION <br /> FOR SANITATION PERMIT <br /> . Permit <br /> -------------- (Complete in Triplicate) <br /> ----------- ------------------------- <br /> -------- ----- - Date Issued --------•- -------- <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 Ordin nce No. 549 and existing Rules and Regulations. <br /> JOB ADDRESS/LOCATIO --- - ------- <br /> " ------- ----�-------- CENSUS TRACT `5 <br /> Owner's Name - - Phone <br /> ___ _.._ _ G ____ ____ ___ __________________________ _ <br /> P_ Cit �.`�-�---------------- ---------- ------•----••------ <br /> Address . ------ - -- --r�---- p -7--�r-- - ---- ----- - -----• <br /> Contractor's Name ttr.c<� R _---- ---------C``'-tk----- - .License # 1 _ __ Phone <br /> - <br /> Installation will serve: Residence. Apament House® Commerc <br /> rtial❑Trailer Court !❑ <br /> 1 <br /> > Motel F-1 Other ---- ------------------------------------- <br /> Number <br /> -------- --------------------------Number of living, unitsc`— TNurraber•' of bedrooms -" '---,-_Garbage Grinder ___.- Lot Size --------------------------------------- --- <br /> •--------Private <br /> Water Supply: Public System and name.------------------------------- ----------------------------------------------------------- <br /> Character of sail to a depfih of 3 f et: Sand'❑ Silt ElClay ❑ Peat ElSandy Loam E] Clay Loam ❑ \ <br /> Hardpan ❑ Adobe'[ Fill Material ------------ If yes,type ---------------------------- <br /> i (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> NEW INSTALLATION: N <br /> --- Liquid Depth ------------------ <br /> PACKAGE TREATMENT i [ ] SEPTIC TANK![ ] Size------------------------ q p <br /> I <br /> ''Ca cit - Type ------------------- Material No. Com artments <br /> a <br /> Distance to nearest: Well ------------------------------------Foundation ---------- ----------- Prop. Line -•---•-•-----•---•- <br /> LEACHING LINE [ ] No. of Lines'-`_------------------ Length of each line---------------------------- Total Length ______-_-----------..------- <br /> ---_-Depth Filter Material ---------------------------------------- <br /> > <br /> -------------------------------- ---•- <br /> 'D' Box _:,.y'_�.._ Type Filter Material _______-_____ p , <br /> Foundation Property Line -------------- --------- <br /> Distance to nearest: Well ----------------------- ------------- - -- <br /> ' SEEPAGE PIT [ ) Depth _ Diameter ---------------- Number ----------------- ---------- Rock Filled Yes ❑ No 0 <br /> Water Table Depth ------- ----------------------------------------Rock Size - <br /> ---------------- <br /> i ----- -� <br /> ---Foundation -------------------- Prop. Line _-.-------------- --- <br /> Distance to nearest: Well _______________--__-- �. <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ---------------------------------------- <br /> Date --------------------•-------------1 <br /> --------------------------- <br /> Septic Tank (Specify Requirements] ------------ ----------------- ---------------------- <br /> Disposal Field {Specify Requireme ts) - t, '` <br /> -- <br /> ----- ----- <br /> -------------------------------------------------------------------------------------------------------------- <br /> IL <br /> k ---------------- ----------------- -r {Draw existing and required addition on reverse side) <br /> I hereby certify that.I have preparedthis 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 /> t sed agents signature certifies the following: <br /> "I certify that in the performance of the work for which this permit is issued, ! shall not employ any person in such manner <br /> as to become subject to Workman's ..ompensati.on laws of California." <br /> 10' <br /> Signed ------------------ -- f? Owner <br /> -------------- J- <br /> a _ __ Title 'ZG� f'r/Z ----- <br /> - ' ---- ----- -------s <br /> (if other than owner) . <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY - DATE <br /> DATE -------------------- ---------------------- <br /> BUILDING PERMIT ISSUED ------------------------------------------------------------------------- <br /> ----------=-------------------------- <br /> ADDITIONAL COMMENTS --------- ----- -------------------------------------------------------------------- <br /> ----------------------------------- - <br /> ------------------ --------- -------------- ---------------------------------------------------------------- -------------------------- <br /> ----= <br /> Final Inspection bY: <br /> .Date -- ----. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />