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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> ------------------ <br /> (Complete in Triplicate) Permit <br /> --------------------------------------------------------- <br /> ---- This Permit Expires 1 Year From Date Issued Date Issued <br /> Application is hereby made to the San oaquin Local Health District for a permit to construct and install the work herein <br /> described. This application is made K in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> � E <br /> J013 ADDRESS/LOCATIO t _____ ;�L " 7- -- 44� CENSUS TRACT _ .__.----------- <br /> 1k <br /> Owner's Name ------------------------------------------------------------ ----��J---�f <br /> AddressQ 7 - CitY -- ------- ••• <br /> Contractor's Name -—------------------------------ ---------------.License # ------------------------ Phone ---------------------------- <br /> Installation will serve: Residence ❑Apartment House K Commercial ![:]Trailer Court 'F1 Y <br /> Motel ❑ Other ----------------------------------------•--- t <br /> Number of living units:--- Number of bedrooms ----------- Garbage Grinder ------------ Lot Size _-_____... _ _ <br /> Water Supply: Public System and name -----------•---------- ------------------------ ------------- ------------------------------------------------Private <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt[] Clay ❑ Peat❑ Sandy Loam -❑ Clay Loam :f <br /> Hardpan..0 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.] W <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 ---------------------.___-. W <br /> Capacity -------------------- Type -------------------- Material---_ No. Compartments ------------------ <br /> to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ---------------------- <br /> LEACHING <br /> .-----------:__ -LEACHING LINE [ j No. of Lines ------ ------------- -- Length of each line---------------------------- Total Length -------------_-_----. --- FI. <br /> 'D' Box ----1------ Type Filter Material --------------------Depth Filter Material --------------------.--------.......... <br /> .._-- } <br /> Distance to(nearest: Well ------------------------ Foundation ------------------------ Property Line. ---.--- ------------ <br /> Number _--____.__-____.______ Rock Filled Yes No C] <br /> SEEPAGE PIT [ ] Depth ___.__;__�______-___ Diameter _-___ ❑ <br /> Water Table Depth ---------- -------------------------------------Rock Size ---------------------------- <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line --___-_-•-_.-_--_--.__\Q <br /> REPAIR./ADDITION{Prov. Sanitation,Permit# -------------------------------------------- Date ----- ---------------------------- t <br /> Septic Tank (Specify Requirementsi)e- - <br /> J------ <br /> ------ - ---------- ------ <br /> - -------- <br /> Dispo I Field (Specify Require _ --__ - D--- - - ----- <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 follo_wing: <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 -----------------------------------------------------------------------------•------------------- Owner <br /> BY ------------------------------------------------------------------------------------------------------ Title --------- --- ----- - ------------ - _ <br /> - - -------------------------------- <br /> (If other than owner) I <br /> -17 FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY .-- --------------------------------------------------- DATE ,57-.X;? 7- <br /> -_-__7o -------------- <br /> BUILDING PERMIT ISSUED ' --------------------------------------- -------DATE ---------------------------------- <br /> ADDITIONALCOMMENTS . -------------------------------------------------------------------------------------------- --- ------------------------=--------------------------- <br /> i <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> i <br /> -- - 6 7-- --------•-- --- <br /> Final Inspection by: - ------------------------------------------------------------------------------.Date <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br /> .i <br />