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FOR O FiCE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> Y - -- -- ------------. <br /> {Complete in`Triplicate) Permit No: <br /> ______________ This Permit Expires 1 Year From pate Issued Date Issued <br /> l <br /> ----------------------------------------- <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 Mules and Regulations: <br /> t JOB ADDRESS/LOCATION -------- --- ------ <br /> --------------•---- CENSUS TRACT -------------------------- <br /> � `- <br /> Owner's Name --W-%4-�-- - - cii�----`- ---------------------------------------------Phone <br /> Address <br /> ---------- //"�`�-------- ��----------- - City <br /> - ----------- ----------- ---------------- <br /> ------------------------------------------ <br /> Contractor's Name -------- ----------------License #f //-------- Phone 6-860 7 <br /> ----- -- ------------------------------- <br /> Installation will serve: ---Residence Apartment House❑ Commercial::❑Trailer Court i❑ <br /> � N Motel ❑Other <br /> \ <br /> Number of living units:__.------ Number of bedrooms ---Garbage Grinder ------------ Lot Size ---- <br /> Water <br /> -Water Supply: Public System and name __---______-\�______--___ _____-----___Private ❑ <br /> -------------------------------------------------------------------- -- <br /> Character of soil to a depth of 3 feet: 'Sa d:❑ Silt ], Clay ❑ Peat❑ Sandy Loam -❑ Clay Loam,E] <br /> Hardpan ❑4�"Aclobe 197 Fill Material ------------ If yes, type ___________________ <br /> (Pl'ot 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 <br /> kI = =publi=c' <br /> 's=-e <br /> wer is available within 200 feet, <br /> PACKAGE TREATMENT-° ]I SEPTICTANK'[ l Size , Liquid <br /> Depth ---------------------.----- <br /> Capacit.Y---------- Type ' Material F <br /> w ---------- No. Compartments -----------•----- <br /> I , / <br /> .,r <br /> Distance�to nearest: Well ___r--------------------- <br /> � � E =-------- •Foundation -------------------- Prop. Line ------------ --------- <br /> LEACHING <br /> -------------------- <br /> LEACHING EINE [ ] No.y of Lines -------- <br /> ______ Length of each-line ---f-------__________-__- Total Length <br /> 'D' 'Box -------------- Type Filter"Nltiterial __________ y_____Depth''Filter Material -------------------------------------------- <br /> Distance...to'nearest: Well i +- � _______Foundation�1_ -------------------- Property Line ------ <br /> ------------- <br /> SEEPAGE <br /> -____ - __SEEPAGE PIT [ t Depth ______________1 [ � `� <br /> Diameter--_______________ Number"--_----._:___.__-.____-_-.__ Rock Filled Yes ❑ No 0 <br /> Water Table De"h <br /> P ---------------------------------------•--------Rack Size ----- --------------------- -- <br /> Distance to nearest: Well --------------------------- --- -- ------Foundation -------------- z---- Prop. Line ---------------------- <br /> REPAIRJADDITION{Prey, Sanitation Permit# ________ ___ _ ______ __________________ Date ____f---------.-__ ____ <br /> Septic Tank (Specify Requirements) __________________ ___ __ --------- ' <br /> -- -- ------- - ----- -------- <br /> -- <br /> ----- ------ <br /> Disposal Field (Specify Requirements) _______ _ _____ <br /> ` ` ! <br /> ------------------------------------------- <br /> ------- - --------------------- <br /> ----------------------------------------------------- <br /> -------------- <br /> raw existing and required addition on reverse side) <br /> I hereby certify that I have prepared this application and that the work will he done in accordance with San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the Saes Joaquin Local Health District. Nome owner or licen- <br /> sed agents signature certifies the following: € <br /> "I certify that in the performance oVtlie work-for whitl-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." j <br /> I I <br /> Signed ----------------------- f --------------------------------------- Owner <br /> �.-- <br /> BY -----------< ------- `- -� -------------------------------------- Title ------- ------------- ------------- - <br /> (I of a than owner) \ <br /> --------------------------- <br /> OR DEPARTMENT USE ONLY <br /> s <br /> APPLICATION ACCEPTED BY -----' --`�[ -- -------- ------------ - --------------- ------------- ----�--. ATE ----�----- - - <br /> BUILDING PERMIT ISSUED ---------------------- - ----- ---------------- --------------- - - ---------------------_---------- -- ATE ------- ---•-------- <br /> ---- <br /> ---------------- <br /> ADDfTIONAL COMMENTS <br /> ---------------------- ------------------------------------------------------------------------ -------------------------------------•-----------.--------------------- <br /> Final Inspection b g( <br /> -- - 0� <br /> P Y ---------------------------------------I-------- -------- --- -- - ------- -Date -------- <br /> ----------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 7-'68 Rev. 5M G <br />