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"FOR OFFICE USE: 40.111 <br /> APPLICATION FOR SANITATION PERMIT <br /> ------- ------- -------------------- <br /> (Complete in Triplicate) Permit No. _7_Z _y Z_9 <br /> � � Date Issued -----'------=-•_--• <br /> ----------------- -- <br /> __ .______0 This This Permit Expires I Year From 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 County Or inance N . 549 and existing Rules and Regulations. <br /> JOB ADDRESS/LOCATION . s �}`' ' <br /> ---.--CENSUS TRACT •-------------------••---- <br /> Owner's Name - -- ----- -� ------------Phone --------------------------------- <br /> Address ---------- ------ l City ---------- ------------------------------------------------ ---- <br /> Contractor's Name -- -_-- - -------- --- - --- - ----------- --------- <br /> cense #1_, . Phone <br /> Installation will serve: Residence ❑Apartment House ❑ Commercial :❑Trailer Court i❑ <br /> •,h <br /> Motel ❑Other -------------------------------------------- <br /> Number of living units:--- ______ Number of bedrooms __ ___-__Garbage Grinde� ----- Lot Size -- -� ;_.__..-..�....._.. <br /> Water Supply: Public System and name -------- -----------------------------------------------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam •❑ Clay Loam ❑ <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,) I <br /> _t <br /> PACKAGE TREATMENT { ] SEPTIC TANK [ ] Size------------------------------------------------ Liquid Depth -_-------------------.----- \ i <br /> \i <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 ---------- ---------------- <br /> 'D' Box ------------ Type Filter Material --------------------Depth Filter Material ---------------------------------------------- <br /> -Distance -to nearest: Well _______------_----_------- Foundation -_-___--___. Property Line-______,___________.:____ <br /> SEEPAGE PIT [ ] Depth _..___._.__________ Diameter ________________ Number --------- ------------------- Rock Filled Yes ❑ No <br /> Water Table Depth -----------=--------------- ---------------_-..Rock Size ---------=---------------------- d <br /> Distance to nearest: Well ----------------------------------------Foundation _______=:---:-`_-'-.,Prop. Line .......I............... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ______.:_______ ........ <br /> Septic Tank (Specify Requirements) ------------ ----------- 1 <br /> -- _ <br /> / <br /> Disposal Field (Specify Requirements) ----_._... /7 �'� ' <br /> ------------------- <br /> -------------- -- ---------------------------------------------------------- -------------------------------- ------------------•----- <br /> fi4 <br /> ------------------------------------------------------- - - ________________.____ _ ___ __ __ _ __ _._ ___ ___________________________.________._____________--____-__-_-_-_----_--_-_-__--_______ <br /> (Draw Existing and required'addition on reverse side) <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with Scin 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 i <br /> --- ------------ - ------- ---- ---------- ---- ---- ---- - ---- --------- Owner <br /> BY - `= ------------------------ Title - --------------------------- <br /> (If other weer} ti G <br /> FOR DEPARTMENT U E ONLY [ � <br /> I <br /> -------- _--- <br /> APPLICATION ACCEPTED BY _ ------ DATE -----�------- F i <br /> .:BUILDING PERMIT ISSUED -------------------------------- DATE <br /> ADDITIONAL COMMENTS ----------------------------------- •-------------------=--------------------------- = - , <br /> � i <br /> -------------- ------- - -- ------ - ------------------/1.--------------------------------------------------------------- -------------------------- <br /> ------------------------------------ ---------- - --------- <br /> ------ <br /> _ ___ _ <br /> --+ <br /> Final Inspection b �� <br /> p Y� ------- ---- J ------- ---.---��------------ - ----•------ ------------------ ---- ---- Date - -------- �---- ------------------ � <br /> SAN JOA U[N LOCAL HEALTH DISTRICT <br /> 1 <br /> E. H. 9 1-'68 Rev, 5M <br />