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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> --------- , -- Permit No. 7-/=--�-� <br /> {Complete in Triplicate} <br /> ---------------------------------------------------------- <br /> ---------------------- This Permit Expires 1 Year From Date Issued 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 is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESSAOI TION .I =„`' �L ---------------------------- --------- ---CENSUS TRACT -------------------------- <br /> Owner's Name ---- t? t � � <br /> ----- � --------------------------:-------------------------------------Phone ------------------------------------ <br /> Address --------------------------- --- w----eoY=:T---------------------- City ----- Z °c�_ <br /> � - --------------------------------------- <br /> 'W <br /> / 5 - Phone u� � Z�JContractor's Name ----- ------------------------------------. __/' � <br /> Installation will serve: Residence �,4partment House❑ Commercial ❑Trailer Court ;[] <br /> Motel ❑ Other ----------------------------------- -------- <br /> Number of living units-------------INumber of edroom�_ _3--_--_-_Garbage GrinderlY'P----- Lot Size _a0__X_tf1 A---___------..------ <br /> Water Supply: Public System and name __- x_-- _ _ --------------------------------------------------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt E:1 Clay ❑ Peat❑ Sandy Loam .0 Gay Loam ❑ <br /> Hardpan ❑ Adobe1 1 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,} W <br /> PACKAGE TREATMENT [ ] SEPTIC TANK,[ ] Size------------------------------------------------ Liquid Depth ---------.--__- --------- L-4 <br /> Capacity - ------------f----- Type -------------------- Material---------------------- No. Compartments -------1---........... <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 /> SEEPAGE PIT [ ] Depth - --------------- Diameter ---------------- Number ------------------------ --- Rock Filled Yes ❑ No <br /> Water Table Depth ------------------------------------------------Rock Size -------------------------------- <br /> Distance to nearesf.Well ----------------------------------------Foundation -------------------- Prop. Line -..._----.--_..._..... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date --------------------------- <br /> Septic <br /> -------_-------------Septic Tank (Specify Requirements) ------------------- <br /> - - -- -� --------------------�----- ----------------------- <br /> Disposal Field (Specify Requirements) ----------- <br /> ___:_,__ �.r--___- 1F <br /> ----------------------------------------------- -------- ------------ -- -------- -- --------------------------------------------------------------------------------------- ------------- ---------- <br /> ------------------------------------------------------- -- --------------------------------------------------------------------------------------------------------------------------------------------- <br /> t {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 Compensation laws of California." <br /> Signed - - ----------- ------------------------------------------------------ - Own i r <br /> By --- --- ------------ ---------------- - Title <br /> (if of e than owner <br /> FOR DEPARTMENT USE ONLY y <br /> APPLICATION ACCEPTED BY ----- + =---- =kk �c _L-�--------- DATE / 7� <br /> BUILDINGPERMIT ISSUED -------------------------------------------------------------- --------------------------- ----------- --DATE -- ---------- ----------------------------- <br /> ADDITIONAL COMMENTS ------------------------------ ------------- IF <br /> ------------ ------------ ------------- <br /> f" ---- --- <br /> ----------------------------------- - <br /> Final Inspection by: -------------- <br /> -------- L,61<---------------------------------------------------------- <br /> -------------------Date __ 10 7`------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />