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FOR OFFICE USE. <br /> APPLICATION FOR SANITATION PERMIT <br /> ---------------------- Permit No. -/4~l <br /> (Complete in Triplicate) <br /> _--.------- This Permit Expires ] Year From Date Issued Date Issued -j------- <br /> -_7o <br /> .-_ <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein <br /> d scribed. Th's appli t' n is made in com Iian�re with oun y Ordinance No 549 and exi ung Rules and Regulations. <br /> JOB ADDRESS/LOCATI N .- .�--s--•f. --------'------------------------------ - -------------------CENSUS TRACT <br /> Owner's Name, --- -- s- r _ ---Phone <br /> Address --Z--1--- -------------------------------------- City <br /> Contractor's Name 4 - _--License # _�� _. P�Phone ------------------------ <br /> Installation will serve: Residence ❑Apartment House� ] Commercial ❑Trailer Court ,❑ t <br /> Motel ❑ Other --------= -- -- - ------ <br /> Number of living units:------- --- Number of bedrooms ---Y----Garbage Grinder ------------ Lot Size ---------------_--------------.------------ <br /> Water Supply: Public System and name ---------------------------------------------------------------------------------------------------------------Private [ <br /> Character of soil to a depth of 3 feet: Sand'o Silt[] Clay ❑ Peat❑ Sandy Loam -❑ Clay Loam ❑ <br /> Hardpan LyJ/ 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,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK{' Size - - - - --------------------- Liquid,Depth --- -----------.--------- <br /> Capacity I-;�_4_e-- -- Type Material--- - --- No. Compartments - <br /> -____.-- .----- <br /> LEACHING LINE [ No. of Lines ----------21-------.-- Length of each line-------5a --------------- Total Length ----/.0-40---------------- <br /> 'D' <br /> _ca-'--..-.-.----- <br /> 'D' Box __ _ __-- Type Filter Material ----A----------Depth Filter Material -----If--" � <br /> Distance to nearest: Well -.--��-�_R__ -- Foundation ----- ------- Property Line. --5------------------- <br /> SEEPAGE PIT [ Depth _ a Diameter ---, 3_----- Number ----------o----------------- Rock Filled Yes '[E" No 0 <br /> � � n o � <br /> Water Table Depth 7a --------- Rock Size _1-_A-Q -------------- <br /> Distance to nearest: Well ------------- G®_'_-------_----.--.Foundation ------1.-o---_--- Prop. Line -..�----------._-- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------- -------- Date ----------------------------------) <br /> SepticTank (Specify Requirements) -------------------------------------------------------------------------------------------------------------------------------------------- <br /> Disposal f=ield (Specify Requirements) -------------------------------•------------------------------------------------------------------------------------ <br /> ---------------------------------------------- <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, I shall not employ any person in such manner <br /> as to become u ject to Workman's Compensation laws of California." <br /> k <br /> Signed -------- --- -------------- ( f ------ -------------- Owner <br /> BY ! Ti#le f <br /> If other than owner) <br /> /; FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY/-- -- ------ <br /> BUILDINGPERMIT ISSUED --------------------------------------------------------------------------------------------------------DATE - --------------------------------------- <br /> TINAL COMMENTS -----------------f----------------------- - - -------------------------------------------------------------------------------------------------------- <br /> ------------------------------------------------------------------------------------=-'-------------------------------------------------------------------------------------------- ------ <br /> s <br /> -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ------------------------------ <br /> ---- -------------------- - <br /> - <br /> ------------- <br /> - <br /> ----------------------- ------------ - -- ---- --------------------------- <br /> Final Ins ection b --------------Dater "v <br /> P Y' <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />