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eFOR OFFICE'USE: —" <br /> �r APPLICATION FOR SANITATION PERMIT <br /> ----------------------------------------- -------- Permit No. -- --�= <br /> (Complete in Triplicate) ' <br /> This Permit Expires 1 Year From Date Issued <br /> Date Issued _!d__ f <br /> & <br /> ---------- ------------------------------------ <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 Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION ----9DI-d_b---- __—S--1`-'- --------------------------- CENSUS TRACT __--i_c�l-------------- <br /> --- AT/4-Mn( ------I _� zo-------------------:--- ----------- -Phone <br /> Owner's Name ____________________ � _ <br /> Address <br /> - l ->\3 -------------------------------------- city __. _2_ �.`-C------------ ---------------------------- -------------- <br /> Contractor's Name --------------------IL ------------------------------------------------License # ------------------------- Phone ----------------------- M <br /> Installation will serve: Residence,[ partment House,❑ Commercial ❑Trailer Court i,',E]l <br /> MoteF1 Other -----------------------------------•-------- 9 <br /> Number of living units-------I--- Number of bedrooms ---3------Garbage Grinder _' -_ Lot Size .___1__ ____--------------------------- <br /> Water Supply: Public System and name -------------------------------•----------- ---------------------------•--•-•--------------------------• ------Private '1 <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> -- �= ""T' Ha�dpan❑ ` Adobe �'Fill'Maf r <br /> --------- -- if yes,type ---------------------------- <br /> (Plot <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'K Size-----------. ----------- ------------ Liquid Depth ___ -- --------------- <br /> Capacity <br /> -- -----Capacity ](9 --------- Type .__ Material t~'L CM4<__ No. Compartments -5------------- <br /> Distance <br /> --- -----Distance to nearest: Well ----------- _20______-..Foundation ----fP----------- Prop. Line ----- __,____---.__ <br /> LEACHING LINE [ ] No. of Lines ----- --------- Length of each line_._____ 0_____________ Total Length ---�P!, ?.�----__ <br /> f. <br /> 'D' Box 40-S--- Type Filter Material�Q -____.Depth_Filter-Material:- -.--------------------------------- <br /> r T ► _1. <br /> Distance to nearest: Well --- �---___--_____ Foundation ----4W _------__ Property Lines_____-- —_t......f <br /> SEEPAGE PIT [ ] Depth ------------------- Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No I1 <br /> WaterTable Depth ------------------------------------------------Rock Size ------------------ ------------- <br /> Distance to nearest: Well -______________________________________Foundation -------------------- Prop. Line _.._______----.-___._. <br /> REPAIR/ADDITION{Prev. Sanitation Permit# -------------------------------------------- Date ____---___________-----------_.--) <br /> Septic Tank (Specify Requirements) ------------------------ ------------------------------------------------------ -•--_ <br /> DisposalField {Specify Requirements) -------------------------------•----------------------------------------------------------------------------------------------------- <br /> ------------- ---------- ---------------------------------------------- --------------------------------------------------------------------------------•-------- <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 C mpensation laws of California." <br /> Signed ert•y --------------------------- Owner <br /> By ----------------------------------- ----------------------- -----------•-----------:------------------- Title ----------------------------------------------------------- ------------ � ti <br /> (If other than owner) <br /> FOR DEPARTMENT E LY J <br /> f <br /> APPLICATION ACCEPTED BY -------------------------- ------ ----- - DATE ---- ----—c9-?--------7------------ <br /> BUILDING PERMIT ISSUED -------------------- ---------------------- ------ ------ ----- ---------- -------------DATE ------------------------------------------ <br /> ADDITIONALCOMMENTS ---------- ------------------------------ --------- ------------------------------------------------------- ------------------------------------------------ <br /> ------------------------ <br /> ----------------- <br /> ---------------------------------- ---- -- ----- <br /> , � /!__ � ------- <br /> Final Inspection 1601!L-el---- ------------------ --- -- ---- Date <br /> ----/------------ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> j <br /> E. H. 9 l-'68-_Rev. 5M <br />