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FOR OFFICE USE: <br /> ;� �- APPLICATION FOR SANITATION PERMIT <br /> ------- - _ __.__- ----------- -- ------ <br /> Z= Z <br /> 1 (Complete in Triplicate) Permit No. - <br /> - - <br /> --------------------------------------------------- <br /> This Permit Expires ] Year From Date Issued Date Issued --- <br /> Application is hereby made to tie 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 ADDRESS/LOCAT N _ ------___ -_" __- , CENSUS TRACT <br /> Owner's Name <br /> _ --- x------------ ----- -------------------------- <br /> - n <br /> -- - ---Pho a .-- --�-- <br /> Address ------ -- �� '`{ -- <br /> ��------------------ city <br /> ! -- ---- --------------------------------------••-- <br /> Contractor's Name ---.--- z -_ e:;) o a r t- <br /> --- ��x --------=-------.License ` Phone Z_X_ -- --2-7 <br /> Installation will serve: 'Resiclence;)(Apartment House-[I Commercial❑Trailer Court ;❑ <br /> Motel ❑Other ----------- <br /> Number of living units:___ _-N'umber of bedrooms Garbage Grinder - tT_ Lot Size .__ c <br /> 4 <br /> Water Supply: Public System and'name -------- ',Ac w:--_--C:4� <br /> ----------------------------- <br /> Private ❑ <br /> E Character of soil to a depth of 3 feet. Sand Silt❑ Clay ❑ Peat❑ Sandy Loam ,E] Clay Loam.0 <br /> i Hardpan ❑ AdobeN Fill Material ------------ If yes, type ___________________________ <br /> (Pl'ot plan, showing size of lot, location of system in relation to wells, buildings, etc, must bJplaced on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepaa e,pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT SEPTt <br /> 6 <br /> lC TANK ]� i - - - - - <br /> Liquid <br /> tm :Capacity '.-- -------- ype ----------- - Material- - ------ -- ---" -- -No. Comarrments <br /> Distance_ to nearest: Well ------------------------------------Foundafiori -----_-------_________ Prop. Line ---------------------- <br /> No. <br /> LEACHING LINE w No. of Lines el <br /> ------ ---- Length of each I'ne__.- . Total Len ----. '-�J'--- <br /> ------� " - - -------- ----- Length <br /> I <br /> ' 'D' Box III-/---- Type Filter Material _ _____ __ Depth Filter Material _. _ ____-"_._ <br /> -------------------•--- <br /> -, a <br />' Distarice'to3 nearest: V1/e!I,__.:- � ---�0:-,.,-____ Foundation ________ Property Line _\k______ ___________ <br /> SEEPAGE PIT —Depth _- -:,-_" ___ Diameter __,�-;?_,Y _f. Number ----------./--------------- Rock Filled Yes ` No i❑ <br /> rte, <br /> i Water Table Depth --�______7_V----------------------_-----Rock Size "---J- - <br /> ---- --------------------- <br /> t , <br /> Distance to nearest: Well _,___ _"__ ______________________Foundation --- __ Prop. Line ____ ______....____ <br /> t <br /> REPAIR/ADDITION(Prev..Sanitation Permit# _I; _. _____.___ Date <br /> --------- -------- 1 <br /> w , <br /> Septic Tank (Specify Requirements) -------------------------------- -------"--------- <br /> ----------------------------------------------------------------------------------- <br /> Disposal Field (Specify Re uirerlments __----__ ,�-� `- <br /> i <br /> ------- ----------------------------------- ------ - - ------------------------------------------ <br /> f (Draw existing and,required-addition on reverse side)•- <br /> 1hereby 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: 1 <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 ------------ <br /> -'-- ---------- --- ----------------- Owner <br /> BY # ------ Title --------- <br /> (if other than owner) <br /> I <br /> FOR DEPARTMENT USE ONLY. <br /> APPLICATION ACCEPTED BY------- ------4.14f---------------------------- [ �7� <br /> DATE -. <br /> BUILDING PERMIT ISSUED ----- -----r------------------------ <br /> ADDITIONAL COMMENTS . ------ I------------ ---------------- ---DATE ------- ----------------------------------- <br /> =� -------------------------- -- <br /> ------------------------------------- ------ <br /> ----------------------------------------------------------- <br /> --------------- --- ---- ----------- ---- --- - -------- -------- <br /> ------------ --------------- - <br /> - <br /> Final Inspection by: -I - ,-------------- <br /> Date --------=----- �'--------- ry= <br /> -. SAN -JOAQUIN LOCAL HEALTH DISTRICT -� <br /> E. H. 9 1-'68 Rev. 5M. <br />