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"FOR GFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> --------------------------------------------------------- <br /> (Complete in Triplicate) Permit No: <br /> ---------// ------- ' <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 /> JOB ADDRESS/LOCATI ------ _ - <br /> CENSUS TRACT <br /> .--- -- - - ----- -------- ------- <br /> Owner's . . <br /> Name ----- - ----- --•--- ------- •- - - ---- - .----- - - one <br /> -t, City Address € --o--e-----------------•--.--.-.------ <br /> # Phn � 4Contractor's Name --------------------� 7 <br /> Installation will serve: Residence ❑ Apartment Ouse Commercial []Trailer Court ❑ <br /> Motel ElOther ._ <br /> Number of living units------------- Number of bedrooms ----------- Garbage Grind ------------ Lot Size _.___._Z___ <br /> Water Supply: Public System and name -------------- ---- ------------------------------------ s 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 /> i <br /> r <br /> -(Plot plan,•.showing-size of lot,.location of system-in,relatiom,fo wells,-buildings,,etc.zmust,be .placed-on .reverse-side.) <br /> I <br /> NEW INSTALLATION: '�(No septic^tank or seepage pit permitted if public sewer is available within 200 feet, �J <br /> PACKAGE TREATMENT Y SEPTIC TANK Size_-_- �.�_________ _______ Liquid Depth _ � li__-_-___. <br /> ` .i. <br /> {.�_ .. .. �p� 1 -�--+-�- � �. <br /> Capalcity�A(�.;; Type ---I I-___ MateriaFrf-tel _G_c_- No. Com arrments <br /> i __ � _ �� - _ _rFoundation ---- Q--fes p ------------------ <br /> pal <br /> -- --•-----------' Distance to nearest: Well _____ Prop. Line .__ it <br /> t , <br /> LEACHING LINE '[� No, of Lines ------�----------- Length of ache Ene___._._C _____..-____ Total Length j.7Q.............. <br /> D' Box - -1/ Type Filter Material _ __ _ .. -�,.__-Depth Filter Material ----- �_______________________________ <br /> ki Distance to nearest: Weil-'_=__ -:_=-Foundation __/D-! t________ Property Line --�_- - `_._._.___ <br /> I SEEPAGE PIT `" Depth _. _____-- Diameter Number _____ _-_._______ Rock Filled 'Yes• No <br /> s p � 0 <br /> Water Table Depth ------------------------------------------------Rock Size <br /> ` Distance to nearest: Well ________________________________________Foundation 1_ __� _____. Prop. Line _...I ---fi_....- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# --------.----------------------------------- Date ---------------------------------- l <br /> tSeptic Tank (Specify Requirements) -------------------- <br /> -------------------- i <br /> sposalField (Specify Requirements) ----------------------------------------------------------------------------------------------------------------------------- ------ <br /> r <br /> -------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ¢ I (Draw existing and required addition on reverse side) <br /> I hereby certify that'[ 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. Horne owner or licen- <br /> sed agents signature'certifies the following: <br /> ( "I certify that in We 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 -- f- - ----- ------------- ----- ------•-------------------- Owner <br /> BY - - -------- - ----------------------------------------- Title -------` r----------- <br /> -------------------------------------- <br /> (if other t owner) 1 <br /> FOR DEPARTMENT U E ONLY <br /> APPLICATION ACCEPTED BY = DATE . <br /> BUILDING PERMIT ISSUED _____________s ''� � - " `}` '^' "j ' 5 1 <br /> ------------- <br /> ---------------- ------------- --------------------------------- -- - DATE , <br /> ADDITIONAL COMMENTS ------------ '-------------------------------------------------------------------------- <br /> i <br /> ------------------------------------- <br /> ----------------------------------------------- ---- i -2 - .- <br /> -- <br /> --------- ----------------------- r --------------- <br /> ---- ------- <br /> Final Inspection by: - WDate S-- "� <br /> / SAN JO LIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />