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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> 104 Permit Permit No. <br /> ----------- <br /> (Compli a in Triplicate) <br /> --------- ------- ------------------------------------- t <br /> Date Issued -. ------------ <br /> This Permit Expires 1 Year From bate Issued { <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. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION .----=----------------- ------ ------ CENSUS TRACT -------------------------- <br /> Owner'ss ` <br /> ---. �� r `---W,, 1 �------------------•------------- -----------------------------------Phone --:----------------- ------ <br /> Address -- _-... /� City <br /> - ------------------ --------------- <br /> --------------------------- 3��� /_ Phone <br /> Contractor's Name ....61 �--------------------------------License ---- <br /> k <br /> Installation will serve: Residence ❑ Apartment House f-1 Commercial ❑Trailer Court i❑ <br /> Motel ❑Other -------------------------------------------- Lot of living units_____________ Number of bedrooms _----------Garbage Grinder ---- __-__._ Lot Size�-� F,�----�------------ <br /> - 1 <br /> Water Supply: Public System and name ------------------------------------- ------------------ ------------------------------------------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand'K Silt❑ Clay ❑ Peat❑ Sandy Loam -❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe [] Fill Material ----- ------ <br /> 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;f ] ' Size----------------------------------------------- Liquid Depth ;--------------------.----- <br /> -------- Type ------/r - <br /> ------- aterial--------------- -- - No. Compartments -----------...-------- <br /> Capacity -. .--.- Yp <br /> Distance to nearest: Well ------- ------ ---------------Foundation -_._--. ---_-- Prop. Line -------------_.------- <br /> LEACHING LINE [ ] No. of Lines __-------------------- Leo each line---------------- --_____--- Total Length ----__----.--..------------ <br /> D' Box ------------ Type Filter Matl .- ------------------Depth Fi er Material ---------------_--------•--------• - <br /> Distance to nearest: Well --------- -- - -- Foundation ____- ----------------- Property Line --:,_---.-------------- <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter -------- Number ... ____ -------_--_-.--_--_ Rock Filled Yes ❑ No <br /> Water Table Depth ------------------- --------------•-------Rock ze ------------- ----------- -----Distance to nearest: Well ----------- -------- ...-Foun ation -------------------- Prop. Line -----•---.--------- ---REPAIR/ADDITION(Prev. Sanitation Permit# -------- - - ---- Date ---_----_-------------------•---Septic Tank {Specify Requirements) ----------------------------- --------------------------- <br /> ---------------------------•..--------------------------- <br /> Disposal Field (Specify Requirements) ---------------------- '---------------------------------------------------- -------------------•--- ----------- <br /> �- <� <br /> - � l= f--------------'' •L� ' <br /> ----- --------------------- --- --- - <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, I shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed -------- -------- ---- -- A --------------------- Owner <br /> ------ -- ------ - ------- - <br /> ------------- Title ------ ----------------------------- ----------- ----------------------- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ----- ------------------------------------------------------------ DATE - -1-x-- ---------------------- <br /> BUILDING PERMIT ISSUED ------------------------------ ------------------------- <br /> --------------DATE ------------------------------------------- <br /> ADDITIONAL COMMENTS ------------------------------------ ----------------------------------------- ----- <br /> --------------------------------------------------------------------------- <br /> - <br /> - -----------------------------------I------------------------------------------------------------------------------------------------ --------------------------------------- <br /> --------------------------------------------------- ----------------------------------------------------------------------------------------------- <br /> ----------- - ----------------- ---------------------- ------- -------------- ------- <br /> Final Inspection by � -_� .Date -- ------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F H- 9 1-'68 Rev. 5M - <br />