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` FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> --- - �/ <br /> Permit No. r_4--_��_ --_A <br /> (Complete in Triplicate) <br /> ---------------------------------------------------------- This Permit Expires T Year From Date Issued Date Issued 7v. <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 compli nce with County Ordinance No. 549 and existing Rules and Regulations: r <br /> JOB ADDRESS/LOCATION ._9 �*± n� .-cf----- ._r -------------------------CENSUS TRACT -2-6/--- <br /> Owner's Name -_1--&f------- ----~'e----gin -- F----------------------------- -------------------Phone ----- --- <br /> Address a ,, <br /> Contractor's Name ------{ '�r ---------------/---'u.-'---- ...License # ---------:-------------- Phone ----------------------------•- <br /> t <br /> Installation will serve: Residence ❑Apartment House❑ Commercial,-" Trailer Court <br /> Motel ❑Other ------------ ------------------------------ <br /> Number of living units_____________ Number of bedrooms ------------Garbage Grinder ------------ Lot Size ____-_________.-__-_._-_.-_________.__---_-- u <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 ❑ <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,j <br /> PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] Size------------------------------------------------ .Liquid Depth -------------------------- b <br /> Capacity -------------------- Type -------------------- Material---------------------- No. Compartments ----------------- <br /> Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ----------...:...----- <br /> LEACHING LINE [ ] No. of Lines ------------------------ Length of each line --------------------------- Total Length -----------.-------.__.._... - <br /> 'D' Box --------- -- Type Filter Material --------------------Depth Filter Material ----------•---------•----------------------- <br /> Distance to nearest: Well ________________________ Foundation ------------------------ Property Line. ---------- <br /> SE E Depth ----/_Q---------- Diameter" ___ .__ Number -------,1------------------ Rock Filled Yes,{ No 0 <br /> Water Table Depth -------0_0-----------------------------------Rock Size _ -- ------L---__ <br /> Distance to nearest: Well ---Zt:lq---------------------------Foundation -4� e <br /> ----------- Prop. Lin . ..----.- -- <br /> REPAIR/ADDITION(Prev. Sanitation Permit=# -------------------------------------------- Date --------------.------------------_} <br /> SepticTank (Specify Requirements) ------ ------------- ----------------------------------------------------------I--------------------------------------------------- , <br /> Disposal Field (Specify Requirements) w �`�2= ''='-�- _ ! -� ? . <br /> ---._,� ---------------------------------------------- <br /> --------- <br /> {Draw existing and required addition on reverse s i d e I <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaqul,� <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner br-!icr <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." I <br /> Signed -------------------------------------- Owner i <br /> BY ` r--� Title - ' �..<w�.� r <br /> - -- - - <br /> ------------------------------ <br /> ---------- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ------ gasr �t ` ----------------------------------------------------------------- DATE '�-d 7d----- <br /> BUILDINGPERMIT ISSUED ------------------------------------------------------------------------------ - -------------------------DATE --------------------------------------••--- <br /> ADDITIONAL COMMENTS ------------------ <br /> ------------------ -------------------------------------------------------------- --------------------------------------------------------------------------------------------------- -------------------- <br /> ------ ------------------------------------------------------------------------------------------------------------------------------------------------------------------------•-------------------- ---- <br /> - � --------------------------------------------=------ <br /> Final Inspection by: q.��� --------- - ----------------------------•------------------------------------- Date _ _��` 7�------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'6$ Rev. 5M <br />