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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ----------------------------------------------- <br /> (Complete in Triplicate} Permit No. .7a-'% )-- <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 County Ordinance No. 549 and existing Rules and Regulations: <br /> { r F <br /> JOB ADDRESS/LOCATIO -------p--l---Q-9-------- f ---� .�1-(� ----------------I------- ----.-CENSUS TRACT ___52-.----------- <br /> Owner's Name -------------T1_��.)- ��^--------------------------------------------------- -------Phone ------------------------------------ <br /> Address ----- ------------- -- ------------ City ---------------------------------------------------------------------------- <br /> Contractor's Name - =--- -- ---------------------------------------- I# C_ 7- ---- Phone I c�' ------- <br /> Installation will serve: Residence C!fA—partment House,0 Commercial ❑Trailer Court I❑ <br /> Motel ❑ Other ------------------------------------- ------ <br /> Number of living units:-----I----- Number of bedrooms ------Garbage GrinderY195------ Lot Size -----l�_________________________________ <br /> Water Supply: Public System and name ----------------------• ---------------------------------------------------------------------------Private <br /> f <br /> Character of soil to a depth of 3 et: Sand ❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> RHardpan ❑,t,t 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 P(No-septic tank or.seepage pit permitted if public sewer is available within 200 feet, <br /> F I <br /> PACKAGE TREATMENT SEPT <br /> [a] IC TANK Si ------------------- --06quid Depth --- _-----____-_________ <br /> CapacityddUr;�___-_,__ Type t_ U�jj..�~___aMaterial:?f1_MCJ--U.-._ No. Compartments ----------------------- <br /> Distance to <br /> __ ______ __________Distance"to nearest. Well ----------- S--____________ _'Foundation ---l0------------- Prop. Line 3_-----_ <br /> ----------- <br /> � r� I -r' ,� <br /> --_------- Length of each°'line-_''____;�D______________ Totaly:Len th __��Q______ <br />� LEACHING UNE [ � No. of Lines ______ _ _ g g _-_--_-__ <br /> � t <br /> — ?- G ---Depth Filter Material ----- -------•-.-_•...... <br /> 'b' Box 4��___.__ Type Filter Material - __ <br /> Distance#to nearest: Well ----- __________ Foundation ---- ------------ Property Line -- ________________ <br /> SEEPAGE PIT [ } Depth _k________________ Diameter ----------------- Number ---------------------------- Rock Filled Yes ❑ No i❑ <br /> Water Table Depth ------------------------------------------------Rock Size -----------------------•-------- <br /> Distance'to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ----------.---.-.----. <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date _______._________________________) <br /> SepticTank (Specify Requirements) ----------------------------------------------------------------------------------•-----•------------------------ --------------------------- <br /> DisposalField (Specify Requirements) ------------------------------------------------------------------------------------------------------------------------------------- <br /> ---------------------- -------------------------------------------------------------------------------------------- <br /> ------------------- --- ----------------------------------------------- <br /> ---------------------------------------------------------------------------------- <br /> I :(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 subjec o Workman's mpensation laws of California." <br /> Signed /�• <br /> ���/ � -------------- ----------------------------------- Owner <br /> By ---------------------------------------- - ----------------------------------- ---- - <br /> --------------- Title ------------ <br /> - <br /> (If other than owner) <br /> FOR DEPARTMEW USE ONLY �,`, <br /> APPLICATION ACCEPTED BY ---- ------------- -(7-_ <br /> ---- DATE ---- '{ l ----- ------------ <br /> BUILDING PERMIT ISSUED ------------ ------ DATE i <br /> ADDITIONAL COMMENTS- ------------------------ -- <br /> ----------------------------------------------------------------------I-------------------------------------------------------------------------------------------------- <br /> - ---------- -- ---------------------------------------------------------------- --- ---------------------------------------------------------------------------------------•---------------------------- <br /> -------------------------------------------------------------- <br /> --------=------- <br /> Final Inspection by: ----------------------- Date S `7 <br /> SAN JOAQUIN LOCAL HEALTHRICT <br /> E. H. 9 1-'68 Rev. 5M <br />