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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION- PERMIT <br /> (Complete in Permit No..Yriplicate) _ <br /> -- -------------------------- -------------------------- <br /> Date Issued _ �v <br /> ------------ -------------------------------------------- = This Permit Expires 1 Year From Date Issued <br /> ------------ <br /> Application is hereby mmcle to rhe 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/LOCATION p �------------------ ---- -------------------- ---------------- TRACT --------------•--=-------- <br /> - - <br /> Owner's Name <br /> Phone ------ <br /> Address ----.-JIX 1P C-------------------------------------------•------=------------. City ---------------------------------------------------- -------------------- <br /> v <br /> Contractor's Name - 7-SLicense #/7-7 -______ Phoner <br /> Installation will serve: Residence [Apartment House❑ Commercial:❑Trailer Court ❑ <br /> Motel ❑Other ------------------'=------------------------- <br /> Number of livingunits:-.-1------- Number of bedrao s - �� <br /> rn _------Garbage Grinder�ti----- Lot Size - ------------------------- <br /> Water Supply: Public System and name ---------------- -------------------------------=---------------------------------------------------Private ❑ <br /> s Character of soil to a depth of 3 feet: Sand❑ Sift[] Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan [1< Adobe'❑ Fill Material ------_--_-- If yes,type..__----------------------- <br /> 3 <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 available within 200 feet,) Q <br /> f '\ <br /> PACKAGE TREATMENT [ ] SEPTIC TANK'f ] Size--------- -------------------------__-___ ____ Liquid Depth -------------------------- <br /> Capacity -------------------- Type -------------------- Material------------- -------- No. Compartments -----------------=•--- <br /> ' Distance to nearest: Well ----------------------------'_.-_-=Foundation ---------------------- Prop. Line -------------:-------- <br /> J <br /> LEACHING LINE [ ] No. of Lines ------------------ ----- Length of each line----------------------- Total Length -------------- -_--_-_---___ <br /> j 'D' Box ----- ------ Type Filter Material --------------------Depth Filter Material -------------------------------------------- <br /> Distance <br /> -----------------------------_- ---•--Distance to nearest: Well ------------------------ Fouridation "------------------------ Property Line ------._----._- ._---- <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number ----- ---------------------- Rock Filled Yes (] No I❑ <br /> Water Table Depth ----------------------------------------------_-Rock Size -------------------------------- <br /> E <br /> Distance to nearest: Well -----------------------------------`---_Foundation -------------------- Prop. Line ----------------.---_. <br /> REPAIR/ADDITION(Prev. Sanitation Permit# --------------------------------4------------ Date ----------------------------------- <br /> Septic Tank (Specify Requirements) ------------------------ ---------------------------------- i <br /> Disposal Field (Specify Requirements) --- =-_--���- --.--- <br /> ---------------------------------------------- <br /> ------------------------------------------------------------------- <br /> --------------------------------------------------------------------------------------------------------------------------------`------------------------------------------------------------------------- <br /> (Draw existing and required addition on reverse side)--- <br /> I hereby certify that I have prepared this application and that I 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 CaliForniio." <br /> Signed ____ -- Owner <br /> -Q---,-�------`------------------------------------------------- <br /> -- <br /> t BY % -------- -- ----- ---- Title ------------------- <br /> --------------------------------- -- ---- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY V -------- ------------------------- ------------------- --------------- DATE --G126 -!'-- <br /> BUILDINGPERMIT ISSUED ---------------------------------------------------------------------------------------------------------DATE -..------------------------- <br /> ADDITIONALCOMMENTS -------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ------ --------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------ ----- <br /> -------------------------------------------- -- -- ------------------------------------ ------------------------------ --------------------6-1---9---- <br /> 81.9- ------- <br /> --- - -- --- - - - <br /> Finalfnspection by: ------------- f V exQ - -- -------------•-•----------------------------- Date <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> #� E. H. 9 1-'68 Rev. M <br />