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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicates Permit No: <br /> ----------`___t <br /> This Permit Expires 1 Year From Date Issued Date Issued _ ......... <br /> Application is hereby made to the San Joaquin Luca) 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 /> }QB ADDRESS/LOCATI N ------ - CENSUS TRACT ---------- -------------•. <br /> Owner's Name - - - 7 -' ; - -�,=.. Phone _ 1 ~_�f. - <br /> Address �b -------- .................... City - :-------------------------------------- <br /> yy <br /> „� .--_ -..License # _ ' 1_�- Phone y f -faK? <br /> Contractor's Name _- _ __ __.__.--------- <br /> Installation will serve Residence Apartment House❑ Commercial ❑Trailer Court ;❑ <br /> Motel ❑Other --- -------------------- <br /> Number of living,units:;__- ____ Number of bedrooms : _ 3-...Garbage Grinder ------------ Lot Size _ _ <br /> Water Supply: public System and name -- ---------------------------------------------------------------------------------------------------------Private ] <br /> Character of sol to a.depth of 3 feet: Sand'❑ Silt,❑ Clay ❑ Peat❑ Sandy LoamClay Loam ❑ <br /> Hardpan ❑ Adobe [] Fill Material ____ If yes,type ---------------------------- <br /> (Plot <br /> _______________________ -(Plot plan, st` lat,, location of system in relation to wells, buildings, etc. must be laced on reverse side.) <br /> Y 9 p <br /> NEW INSTALL Ai `tic tank or seepage'pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TRt? :SEPTIC TANK[ Size------------------------------------------------ Liquid Depth ------------------•--. <br /> city;----- -- - - Type"-_-i- - Material-- --------------- No. Compartments --- --•--- <br /> 4 to nearest Well ------------------------ ------------Foundation ------- ------ ----- Prop. Line ---------------------- <br /> LEACHING LINE �k <br /> j; Lines _ ___ -__--__ L"nth 'of each line---------------------------- Total Length ,____-____--_ <br /> Type Filter Material ......Depth Filter Material ........................................_ _ ....__ <br /> to nearest: Well ------------------------ Foundation ------------------------ Property Line .___-___-.•_____________ 1 <br /> SEEPAGE PIT [ ] „_ _ ___________ Diameter. --------------.. Number ---------------------------- Rock Filled Yes ❑ No ,C <br /> U�/afr:'Table Depth ------- ---------------------------------------Rock Size --- <br /> D9stance to nearest: Well ----------.--------------------Foundation -------------------- Prop. Line -----.----_-- ........ <br /> REPAIR/ADDITION rP�ev.'Sanitation Permit# -1--------- --- - x�t` _______ Date _-_ <br /> SepticTank (Specify Requirements) -------- -- ---- ------------------- --------------------------------------- ------------------ ------------------------------------- <br /> Disposal Field (Specify; Requirements) � ----------------------------------- <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, I 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 th owner) <br /> FOR. DEPARTMENT USE ONLY ,- <br /> APPLICATION ACCEPTED BY ------ ---- -- - -- -------------------------------------------------------. DATE ------ --------------- <br /> BUILDINGPERMIT ISSUED -- -�---------------------------------------------------------------------------------------DATE _----------------------------------------- <br /> ADDITIONAL COMMENTS -------------------------------------•------------------------------------------ - <br /> ------------------------------------------------ ---------------------------------------------------------------------•----------------------------------------------------------------------------------- <br /> -------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ----------------------------------------- -------------- <br /> Final Inspection by - ---Date -- " _ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />