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FOR OFFICE USE: PLICATION FOR SANITATION PERMIT <br /> ---- - -- --- ---- -- ---- Permit No. - c�4 <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 o nfiy rdinan No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LO TION _"" �-_!_.(_-- -- ---��----------------------------- - ---- <br /> ------- Y CENSUS TRACT -------------- ------- <br /> Owner's Name . ._ Phone -._-�Z 3 - � <br /> -------------------- ----------------------- ----- ------------------------------ <br /> Address -...-- `�t� City <br /> {----------------- ---------------------------------------------•- -----------------------------------...----------------_------ <br /> Contractor's Name ------------- � 7 S-_ ---.License #17.7It��____...._ Phone <br /> Installation will serve: Residence Apartment House Commercial ❑Trailer Court C] <br /> Motel ❑Other ----------------------------------- -------- <br /> Number of living units:------ 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'E!J'*"Silt 0 Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam.El <br /> Hardpan ❑ Adobe ❑ Fill 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,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK f j Size------------------------------------------------- Liquid Depth ----------..._-•.----_---- <br /> Capacity -----------------•-- Type -------------------- Material---------------------- No. Compartments ----------------------- <br /> Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ---------__-----•__-- .� <br /> LEACHING LINE [ ] No. of Lines ------------------------ Length of each line---------------------------- Total Length :-----------------__-_______ G <br /> 'D' Box ------------ Type Filter Material ____________________Depth Filter Material -----------------------—.....----.__. -_.. <br /> Distance to nearest: Well ________________________ Foundation ------------------------ Property Line ------.----------,-:------ <br /> SEEPAGE <br /> ___ -SEEPAGE PIT [ ] Depth -------------------- Diameter -------- ------- Number ---------------------------- Rock Filled Yes ❑ No <br /> WaterTable Depth ---------------------------- -------------------Rock Size -------------------------------- <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ................. <br /> .__.. <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ---------------------------------- <br /> Septic <br /> --------_-----------------------_Se tic Tank (Specify Requirements) __ iC---------_________________ <br /> Disposal Field (Specify Requirements) -- --- .--• ---_--,_- --_----- ----------- _ Q_ <br /> ------ --- ------------- <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. 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, 1 shall not employ any person. in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed ------ ------- Owner <br /> By ----- - � ---------------------------------- Title -- ``�_ ------------------------------------------------ <br /> (If other than owner) <br /> y� �FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -------/ 4 / �.------------------------------------• DATE __�� . -�/� ------------------ <br /> BUILDING" PERMIT ISSUED ----------- -- ----------- DATE ------ _ <br /> ADDITIONAL COMMENTS ,r�_ _ IL � ll------------- <br /> P` <br /> - ---------- - ----------------- - ---------------------- ----- --------------------- ----------- <br /> - ----------- -------- -----r ----------- -------------------------- <br /> - ----- ----- ------------ _ <br /> - ------- <br /> Final Inspection by: .- ----- �rz`{/< --------- ------- -- --- ------------------Date ------✓ - --- ?� L <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> H. 9 1-'68 Rev. 5M. x <br />