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FOR OFFICE USE: <br /> ,, APPLICATION FOR SANITATION PERMIT ,% C <br /> T-/---7Z1---------------t�---' _moi Permit No. -- 1"/ <br /> - - <br /> (Complete in Triplicate) <br /> --------- t== �© <br /> (� �. Date Issued .____-_-r_-___ _ <br /> - t __._------ ------ This Permit Expires 1 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 Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/L ATION , /_- _ l _._ - -CENSUS TRACT <br /> �,✓. /. yeC�2�� _ '' Phone y�! <br /> Owner's Name k -_ -_ ` -- <br /> �Address --- -. City ---- ------------------------------ <br /> ----- <br /> --- -- -- ------- <br /> Contractor's Name - '� - =_ <_ _ __-____.____-_.License # : '-y!7%--- Phone _ f` <br /> Installation will serve: Residence ❑Apartment House❑ Commercial ❑Trailer Court ;❑ <br /> Motel F1 Other ' s <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❑ Silt'❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam '❑ <br /> Hardpan ❑ Adobe Z' 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 [ I SEPTIC TANK [ ] Size------------------------------------------------ Liquid Depth ---------------------- <br /> Capacity <br /> ._.-_-__-_-_-------- <br /> Ca acitY - -------- TYPe ___________________ Material---------------------- No. Compartments _____.._.-__.._...... <br /> �. <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 [ J Depth -------------------- Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No i❑ <br /> WaterTable Depth ------------------------------------------------Rock Size -------------------- <br /> Distance to nearest: Well ____-_________-______________________Foundation -------------------- Prop. Line ___-____---__--__--_- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ---- --- -- � _ Date _____ _____ _)< , <br /> -s Septic Tank (Specify Requirements) _-_-- -- ---_-_----- <br /> Di posal. Field (Specify Requirem ------- <br /> S) ------------------------------------ <br /> /f <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 be44me subject t ;Wor +can's Compen on laws of California." <br /> � —� <br /> Signed ct�'Gr" 4 -------- Owner <br /> , / - <br /> -------- -------- ------- -------- --------- <br /> BY - C _C --� --- ----------------------- Title <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY - _- ? --------------------------------------------- DATE --TU__ <br /> BUILDING PERMIT ISSUED ___. _ .._ . DATE _ --------- <br /> ADDITIONAL COMM NTS^ <br /> _____--__-- -_ ___-______ _ ___---_--_-_.__-_--______-__-___.-____-_-_---____--_____-_____._-___-____-____--__ <br /> ____-_______--_- <br /> Date 7- <br /> Final Inspection ------- -- - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />