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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ..- •-- -•--, Permit No. .............. <br /> (Complete in Triplicate) <br /> ........................... .. / <br /> --• ...7... ... <br />......................•.,---....._..-.........--.... This Permit Expires 1 Year From Date Issued Date Issued ... . .7 <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 modelin compliance�it ounty Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION . ....... i.r../.1. - - .- !:f�--?.CENSUS TRACT ........ _....... <br /> ......... <br /> Owner's Nome ..._ Phone ..............•..................... <br /> . <br /> Address �l° 3 'ty ---------------------------•--•. ................ <br /> moi..__ ... <br /> Contractor's Name ...... `.................::License # ��.CQ:`C�� Phone _ .1 <br /> Installation will serve: Residence-E) Apartment House❑ Commercial []Trailer Court a <br /> Motel ❑Other ---------------- ---- <br /> Number of living units:....... Number of bedrooms ..-......Garbage Grinder _.�- Lot Size .._ CW1 jr,_�-____ . - <br /> Water Supply: Public System and noIme ..------- ............... ..........................•--_ -_.....__.......... ----------- ...................Private <br /> Character of soil to a depth of 3 feet: Sand'A . Slit❑ Clay ❑ Peat❑ Sandy loam ❑ Clay Loam n <br /> - Hardpan ❑ Adobe {] Fill Material .......... If yes,type ........... ....... <br /> V <br /> (Plot ,plan, showing size of lot, location of. system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> t <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public,sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ SEPTIC TANK{ ] Size_..._...9_�Z__ ._... ......... Liquid Depth _..._.__../............. <br /> Capacity -_n'-U-�7-...... Type 90.r.�5t. Material__ . ._ . .w]`_ No. Compartments ...2. <br /> t <br /> Distance to nearest: Well ...3�r' . ..... x2.-.._..'.Foundotion ...2_d........ Prop. Line _ ..... <br /> LEACHING LINE [ ] No. of Lines Length of each line...... ../.............. Total Length .47.............. <br /> D Box Type Filter Material ..�. �-_.....Depth Filter Material ..f_ l� <br /> Distance to nearest: Well ________________________ Foundation Property Line I <br /> SEEPAGE PIT [ Depth Diameter ....a::...a.. Number .............. Rock Filled Yes ❑ No (] <br /> Water Table Depth ..................................... <br /> : .Rock Size <br /> Distance to nearest: Well ...............:........................Foundation .................... Prop. Line ................... <br /> � S <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ............................................ Date ................................... <br /> SepticTank {Specify Requirements) ................................................ ..........................,__..---------.......................-.__--_-_----------- u• <br /> Disposal Field (Specify Requirements) ... --------------------------------- ------------------------------------------------------ <br /> f <br /> ------------- ............................................. ----------------------..._._............._..........•-•------------------4-- <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: f <br /> "1 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 .,-- C�, . • •---•..... ........................... Jitie .............------.--............ ---------------- .................. <br /> (if other than owner) ' <br /> FOVDEPARTMJNT USE ONLY i <br /> APPLICATION ACCEPTED BY .. . . .... .... ... . .......... --•---•---....... ............................. DATE _.� -45=Z,7 .------•-- <br />' BUILDING PERMIT ISSUED _ ---- .............••_ ••--•...............•---...--•-••-._.1...-----------DATE ........................................... <br /> ADDITIONALCOMMENTS ................................................................._...............---...............................:.............:............ <br /> ...........................•---•-----•-•-•-----• .................................................... ............................ ........................................................_.......... <br /> Final Inspection by, ......... .............Date ��- -----_____- .----_-. <br /> SAN JOAQUIN LOCAL' HEALTH DISTRICT <br /> E. H.13 24 1--.68 Rev- SM W – 7/723M <br />