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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> --- -------- -- ------------•-- - -------- Permit No. <br /> (Complete in Triplicate) <br /> ---------=-- ---- ---------------------- ---- <br /> This Permit Expires 1 Year From Date Issued s- <br /> ----_-_ __ <br /> -------------------------------- -----------__ <br /> Date Issued ___ ------------- <br /> _-r <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 complia ce with County Ordinance No. 549 and existing Rules and Regulations: <br /> :97� <br /> q1S — '------------------------------ -----CENSUS TRACT ------------- ----------- <br /> JOB ADDRESS/LOCATION -------------`3 <br /> Owner's Name r��r -------- Phone <br /> ------1+-l'• Apina cz:-------------- city ---------------------- <br /> Contractor's Name -------(_i',A-----------------------------------------------------------------------License # ------------------------ Phone -------------------- --------- <br /> Installation will serve: Residence.El Apartment House❑ Commercial :E-]Trailer Court 0 r <br /> Motel ❑Other ------------------------------ -•------....- <br /> ll Fr <br /> Number of living units:-- --l.-- Number of bedrooms --- -----Garbage Grinder"---.----- Lot Size .- ------- <br /> Water Supply: Public System and name ---------------------- ----------•----------------------------------------------------------------------A Private <br /> Character of sail to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam.❑ <br /> Hardpan ❑ 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 seep a pit permitted if public sewer is available within 200 feet,) , <br /> PACKAGE TREATMENT [ ] SEPTIC TANKSize-------- ------------------------- Liquid Depth ------1l---- ----------- <br /> / TYPe ......... <br /> -" ' Material` -"� _ No. Compartments ------- ---••..•--. <br /> Capacity <br /> <c--r <br /> Distance to nearest: Well -------WIVA f-------------------Foundation ____- ----------- Prop. Line ... .....-_.- <br /> LEACHING LINE [ ] No. of Lines _____------------- Length of each line---------------------------- Total Length __-._-_.-.....-_----.--._ V <br /> ®®., 'D' Box ------------ Type Filter Material --------------------Depth Filter Material <br /> r—/c.��i i31F_D r `� <br /> Distance,to nearest: Well - ,------n', Foundation -------------------_--- Property Line. --- ---------------- <br /> SEEPAGE PIT [ ] Depth ----- ----------- Diameter ----- -- Number ----------1 .-.------__-- Rock Filled Yes E3--No C1 <br /> WaterTable Depth ------------------------------------•-- --------Rock Size -------------------------•----•- <br /> Distance to nearest: Well -------T;(--f--------------------Foundation -------------------- Prop. Line ---------------------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ------------------ <br /> ---------------- <br /> Septic Tank (Specify Requirements) ----------------------------- ------------------------------- <br /> ----------------------••----------•----------- ----- <br /> 1 <br /> Disposal Field (Specify Requirements) ----------------------------------------------------------------------------------------------------------- ------------------------- <br /> ------------------------------------------------------- -------------------------------------------—------y-------------------------------------------------------------------------------------------- <br /> ------------------------------------ ---------------- ---- ---------------------------------------------------------------------------------------------------------------------------------------------- <br /> (Draw existing and required addition on reverse side) <br /> f - <br /> 1 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 subject to Workman's Compensation laws of California." <br /> sSigned -------------------------------------------------------- Owner <br /> ------------------------------------- Title ----------------- ---- <br /> (If other than owner) <br /> FOR .DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY --------- - ---9- DATE ------ <br /> 3 5------- <br /> BUILDINGPERMIT ISSUED ---------------- ---------------------------------------------------------------------------------------DATE -------------•---------------•----------— <br /> ADDITIONALCOMMENTS ------------ - -------------------------•---- ---- ---------•------------------------------------------------------------------- --------------------------- <br /> --- ------ ---- -- ------------------- -- ----- -- --- -- ----------------------------------------------------------------------------------------------------- <br /> [ ------- ------------------------ - --------- - --------------------- --- ------- ---------- ------------------------------------------------- ------------------------_--- <br /> ------------------ <br /> 5 —. <br /> Final Inspection : -- Date -._- -------------------------------------- <br /> 2-5, <br /> ---- ------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />