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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT / <br /> --- ------ - - Permit No.�� -- J <br /> (Complete in Triplicate) <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 compliances with County Ordinance No. 549 and existing Rules and Regulations: <br /> - <br /> JOB ADDRESS/LOCATION -------- ,----'Y'---- � <br /> ---- l_=-------------- -------------------------- ---------CENSUS TRACT -------------- ------------ <br /> Owner's Name .�... --- -------Phone--------------------------••-------- t: <br /> gwAddress ------------------------------ --- - City •------- <br /> Contractor's Name --------04&7> -------------------------------------------------------------License # ------------ ----------- Phone ---------------------._....-._ <br /> Installation will serve: Residence 60-4artment House❑ Commercial ❑Trailer Court i❑ <br /> Motel ❑ Other ------------------------------------------ _ <br /> Number of living units.-_/----- Number of bedrooms <br /> , --:-�----Garbage Grinder--_-- Lot Size �-����_-1��-�-------------- <br /> Water Supply: Public System and name --- � "3 ------------------------------------•-•----------------------------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand [] Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe 2--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 f[" Size--------------------------------------- ----- Liquid Depth -------------------------- <br /> 011 <br /> Capacity -/..=___------ Type _-- No. Com <br /> --- Materia - -- Compartments ---' .--•--•---=--•. <br /> Distance to nearest: Well -_---------------------------------Foundation ..../0 Prop. Line --- - .:------_- d <br /> LEACHING LINE [ ] No. of Lines ----�J---------------- Length of each line-----RD---------- ------ Total Length __ _--..------__. <br /> 'D' Box VA->----- Type Filter Material Depth Filter Material -----/'� .............................. <br /> Distance to nearest: Well --------- `.-.------ Foundation ----642.-P------------ Property Line ----5- .-.__.-._-. . <br /> SEEPAGE PIT [ ] Depth -------------------- 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 /> Septic Tank (Specify Requirements) -------- ------- --------------- -------------------------- •----------------------------- <br /> DisposalField (Specify Requirements) ------------- ---------------------------------------------------------------------------------------------------------------------- <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 Son 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 /> Signed 4 ----- -- ---------------------------------------- Owner <br /> BY -------------------------------------------------------------- Title ------------------- -- ------------------------------------------------- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -- --- ------------- ------ ----------- -- -- ----- --------------------- DATE ---1-4 77-J------------------------ <br /> BUILDING PERMIT ISSUED ---- --------------------------- ------ ------- ---------- ---- -------DATE - ----------------------------------------- <br /> - ------- ------------- <br /> ADDITIONAL COMMENTS ------------------ --------- ------------------------------ ---------------------------------------- ---------------------=--------•------------------ <br /> ------------------- -- ------- --------------------------------------------------------------------------------------------------------- ------------------------------------------------------------ <br /> -------------------------- ----------------------------------------------------------------------------------------------- ---- - -- ------------ ----- <br /> ------------------------------------------------------- ------------------------- ------------------------------------------ <br /> --------------------- <br /> ------- ------- --- ---- -- - -- <br /> ---------------------- <br /> FinalInspection by- --------------------------- -------------------------------------------------•------------- -----Date --- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />