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FOR OFFICE USE: , <br /> APPLICATION FOR SANITATION PERMIT <br /> ' ------------ - ---- ------- ---- 7 Z 5 a-6 <br /> - - Permit No. <br /> [Complete in Triplicate) <br /> --- ------- ----- ------------ <br /> i° <br /> -------------------------------------------------------- This Permit Expires 1 Year From Date Issued <br /> Date Issued. -�-y_� <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 /> ]Q n s �j <br /> i JOB ADDRESS/LOCATION -----1_r- ,------ ---5- ---J_ ---- - -[-- -----------------------CENSUS TRACT --9tr_ _---- <br /> Owner's Name --------- ` ---------- ----------•----• --------- ------------Phone <br /> Address -- ------ f'Y- * 1N --. Ci# f ��_ _ �f <br /> _ R ---- Y 1- <br /> Contractor's Name -�-` ,rf � � ! <br /> License Phone <br /> x <br /> Installation will serve: Residence ❑Apartment House❑ Commercial ❑Trailer Court ;❑ <br /> Motel Other _-_---_- -- <br /> Number of living units:__- -f ---Number of bedrooms ---.��_------Garbage Grinder ------------ Lot Size —--------------- <br /> Water Supply: Public System and name ---------------------------------------------------------------------------------------------------------------Private [ <br /> Character of soil to a depth of 3 feet: Sand'R Silt 0 Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam .E] <br /> Hardpan ❑ Adobe ❑ Fill Material ------------ 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 /> } r <br /> { ..- NEW INSTALLATION: (No septic tank or seep a pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT SEPTIC TANK Size-----_ <br /> [,� � -- -�-- ----- -- quid Depth --�-��------------ <br /> Capacity i -C7_.__ TypeMa#erial <br /> -- cam No. Compartments .. <br /> istance.: to nearest: Well -_---it ------t--------------Foundation __-.- -- _-r-___ Prop. Line - f ,------ <br /> [ No. of 1 <br /> LEACHING LINE Lines ------ ------------- Length o each line______ __ _________ Total Length ,/�p__.-__-._-___ <br /> J <br /> D' Box _---- ------ Type Filter Material A-4--_j;5:�Depth Filter Material -----1- -`----------------------------- <br /> Distancel to nearest: Well -----r� i---- Foundation ----- l O. Property Line --- --------._- <br /> SEEPAGE PIT [ ] Depth '_ ------------------ Diameter ---------------- Number ----------------------------- Rock Filled Yes '❑ No I❑ <br /> WaterTable Depth ------------------------------------------------Rock Size -------------------------------- <br /> f <br /> Distance+to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line --------_--_------_--_ <br /> REPAIRJADDITiON(Prev. Sanitation Permit# -------------------------------------------- Date ---------------------------------_} <br /> i 1 <br /> Septic Tank (Specify Requirements) ----------------- ---------------------------!.---------------------------- <br /> Disposal <br /> ----------------------•---- <br /> Disosal Field (Specify Requirements) ----------- --------------------------------------------------------ti---------------------------------------------------- ----------' <br /> 1 ' <br /> ------- <br /> (Draw existing <br /> ired addition on reverse side) <br /> I herebycertifythat I have prepared application and thate <br /> 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 t Work it's Compensation laws of California." <br /> Signed ---- - ----- --- - -------- ------ Owner <br /> BY ------- (I� of er a ---------- Title ------------------- <br /> ----------- ---------------------------------------------------- <br /> n owner) <br /> '1, p FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED ;BY - --------­� C_R -------------------- - -- " 7 "----- <br /> DATE �I--- ------ <br /> BUILDING PERMIT ISSUED ------- 4 ---------------------------------------- ---------------DATE ----------------------- <br /> ------------------- ------------------ <br /> ADDITIONALCOMMENTS ------- ----------------------------------------------------------------------------------------------------------------------•------------ <br /> ---- ------------------------- ---- -- ---------------------- ---------- <br /> ------------------------------ - --------------------------------- ------- ---------------------- --------------------------- - <br /> --- ------ m - - ---------------------- <br /> bY ----- -- - -- - �------ ----- -----=- Date --- -J <br /> --------- ------ <br /> Final Inspection ------- <br /> SAN <br /> JOAQUIN LOCAL HEALTH DISTRICT <br /> i <br /> E. H. 9 T-'68 Rev. 5M, <br /> k <br />