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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> R----------- <br /> (Complete in Triplicate) Permit No. <br /> Date Issued .---.--.-" <br /> ------------------------------------------ <br /> ,,,,,,,,,,,,,,, This Permit Expires 1 Year From Date 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 's made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> .���� �../lJ+�� f"'t O Q✓� r r .� � -_-_ p 1�, � .— �-['-Cam['-s�.s .�9 O <br /> JOB ADDRESS/LOCATION ,.Lr TRACT -------Sy_V------_--- <br /> Owner's Name -- ---�-------- -- -- ---- -- -- - -------------------------------------------- - --- ------•----I-------------Phone ---------------------- - - - <br /> Address -------- �_ -.4.. f�- -- --------- �C,tY / - ------------------------ ------ <br /> Contractor's Name ----- --- -- --------- � ---- License # _`ZF34F?� hone ----- ------------------------ <br /> Installation will serve: Residen a [Apartment House❑ Commercial ❑Trailer Cowl❑ <br /> Motel ❑ Other ---- ------------------------------ <br /> Number of living units:-_---L_` Number of bedrooms -_-----Oarbage Grinder .----------- Lot Size ----___ ___--------------------- --------- <br /> Water Supply: Pulalic System and name --------------- ---------------•-•----------------------------------------- - ----- Private [�}� <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt E] ❑ Peat E] Sandy Loam Clay loam ❑ <br /> Hardpan ❑ Adob _. ill Material ------------ if yes, type ------------- -------------- <br /> JPIot 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:[ ] Size------------------------------------------------ Liquid Depth ---------__----------. --- � <br /> Capacity ---- -------------- Type ----- -------------- Material ---- --------------- No. Compartments ---------•- .......... <br /> Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ------- -------------- 7 <br /> LEACHING LINE [ ] No. of Lines ------------------------ Length of each line---------------------.------ Total Length -------.------_-_-----._--- �p <br /> 'D' Box ------------ Type Filter Material ---_---------------Depth Filter Material --------------------_-----. 1--------------- _ <br /> Distance to nearest: Well ------------------------ Foundation ---------------------- Property Line -----------------.-----. <br /> -f <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter --------------- Number --------------------- ------ Rock Filled Yes ❑ No 0 <br /> Water Table Depth ------------------------------------------------Rock Size ----------------------- -------- <br /> Distance to nearest: Well ----------------------------------------Foundation -.--.--------------- Prop. Line -_----_-_____---_--- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) <br /> Septic Tank (Specify Requirements) - ------ <br /> I-----------"' f Dis osal Field (Specify Requirements) -------- <br /> y <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. Horne 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 Co pensati.on laws of California." <br /> Signed -------------------------------- Owner <br /> BY Title <br /> --- ---------------------------------------------------- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -- ✓ -------------------------------------------------------------- DATE ---$ - 7- <br /> BUILDINGPERMIT ISSUED ------------------------------------------------------------------------------------- ------------------DATE ---------------------- --------------- <br /> ADDITIONALCOMMENTS ----------------------- -------------------------------------------------------------------------------------------------- ---I-------- -------------------- <br /> ------------------------------------------------ ----------------------------------------------------------------- -------------------------------------------- ) ----------------- <br /> ---- ---- --- ----- ------------- ° ---------- - -------- ----- <br /> Final Inspection by: ------------- <br /> ------------- --- - -------.Date . -�T`-7 -------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />