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FOR OFFICE USE: '�� 7G-ep S A v� 7°3- 2`7� <br /> APPLICATION FOR SANITATION PERMIT <br /> a `----------- ------------------------ <br /> (Complete in Triplicate) Permit No. <br /> This Permit Expires 1 Year From bate Issued <br /> ----- 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 de in compliance y{it� County Ordinance No. 549 and existing Rules and Regulations. <br /> 4110 -Vo wlW 79 <br /> JOB ADDRESS/LOCATION ._ ® CIJ -rt•+ •-,(���'f- - - _ '�'-'-`"�__._.-----CENSUS TRACT -------------- ----------- <br /> Owner's Name ----- _ ---- -- --'--------------------------------- -------Phone ------------------------------------ r <br /> Address - 9 -- -- -- ------------------------------ ---------- City ---------------------------------------------- <br /> Contractor's Name ----- -__-License 3Phone <br /> Installation will serve AA artM ���Commerciarailer Court C] <br /> Motel ❑Other -------------------------------------------- <br /> Number of living units_____________ Number of bedrooms ------------Garbage Grinder ------------ Lot Size __________________-____-_________-----__. <br /> Water Supply. Public System and name ------------------------------------------------------------------------------------------ -------------------Private 41 <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam .I❑ Clay Loam,Z <br /> Hardpan ❑ Adobe ❑ Fill Material --_-_-______ If yes, type ---------------:-------------- <br /> (Plot <br /> ___________(Plot plan, showing size of loft, location of system in relation to wells buildings, etc. must be placed on reverse side.) V ' <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted.if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT ( 7 SEPTIC TANK Siza-_"__ --I-------------- -- Liquid Depth _ ---?►--------------• 1� <br /> Capacity A.y_-_______ Type `__ Material- - _ __�__ No. Compartments __. _................ <br /> Distance to nearest: Well ----- _—_____________________Foundation __IQ-------------- Prop. Line --_______------ <br /> ---6-------- -------- Length of each line-4- ------------ <br /> LEACHING LINE � No. of Lines _____ Total Length _�_�_�_________________ ' <br /> 'D' Box - ,�._-_ Type Filter Material s_ ____.---Depth Filter Material -�r--_________-------- <br /> _______________ <br /> Distanc to nearest: Well ------------ Foundation 10- _____________ Property Line .............. <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number ___________________________ Rock Filled Yes Q No <br /> WaterTable Depth ------------------------------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well ________________________-_-________--_.Foundation -------------------- Prop. Line ----------..____-___-. <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) <br /> SepticTank (Specify Requirements) ------------------------ ------------- -----------------------------------------------------------_----------------------------- <br /> Disposal Field (Specify Requirements) ----------- --------------------------------------------------------------------------------------------------------- --------------- <br /> -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------ <br /> ------------------------- ----------------------------- -------------- ---- ------------------------------------------------------------------------------------------------------- ------------ <br /> _ (Draw existing and required addition on reverse.side)T <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 . ------------------- ------------------------------------------------. Owner <br /> BY Title _n -"f��--------------------------------- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ------------------------------------------------------------ DATE _4_._/_Y"71i--- --------(Z:' - <br /> BUILDINGPERMIT ISSUED ----------------------------------------------------------------------------------------------------------DATE --------------------------------- --------- <br /> ADDITIONALCOMMENTS --------------------------------------------------------------------------------------------------- ------------------------------ ----------•---------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> --------�-------------------------------- --------------------------------------------------------------------------- - - <br /> - --------------------------------- ----------------------- - <br /> - ---- - --- - --- - --- - --- -- - -- <br /> Final Ins ection b _ Date ! ________________ <br /> ---------------------------------------------- ----------- ---- ---- ---- - - -- <br /> P Y <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />