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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> --------------- ----- ------- - t: Permit No. ----7d------------ <br /> ---------------- <br /> --------- <br /> --- -j <br /> --------- ----------------- <br /> [Complete�n Triplicate} <br /> ----------- <br /> Date Issued <br /> This Permit Expires 1 Year From 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 /> pp ---- - CENSUS TRACT -------------------------- <br /> JOB ADDRESS/LOCATION .- _--l- - -- ------ <br /> Owner's <br /> - ------ one_. <br /> Owner's Name,.J, •��- ---- - - -- � - - --- -- -- ------------------------- ---------- <br /> W, <br /> -----4.74V--- -�e- ' City �, <br /> Contractor's Name -- -- -----------------License # -�8x � - Phone -----------------------•------ <br /> Installation will serve: Residen [ `partment House❑ Commercial ❑Trailer Court ;❑ <br /> Motel.F-1 Other - ------------------------------------------ <br /> Number of living units:-------1--- Number of bedrooms _3-----Garbage Grinder .___----- - Lot Size -------------------------------------------- <br /> Water <br /> ----_-- -------------_--_-_----_Water Supply: Public System and name ---------- -----------------------------------------------------------•-----•---------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand'[] Silt❑ Clay ❑ Peat ❑ Sandy Loam -❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe ZFill 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 see age pit permitted if public sewer is available within 200 feet,) { <br /> PACKAGE TREATMENT f I SEPTIC TANK![ Size'!5" _Ao----X__5. .............. Liquid Depth - .--- <br /> r � <br /> l <br /> Materia ---- No. Compartments r�-------•-- <br /> =---- <br /> Capacity _��o to _ - TYPe --- ----- i � <br /> aao- Foundation ------/!P ---------- Prop. Line .---`-'�-------- <br /> .4 <br /> Distance to Weare Wel! ____---____�---- --`t- --�---- <br /> LEACHING LINE ['I No. of Lines 0-2---- Length of each line------'te l----------- Total Length _-� a-------•-- ---- `jJ <br /> 'D' Box -_ ------ Type Filter Materia! --------------------Depth Filter Material -f---------------------------•------- <br /> Ov ` /-� Property Line --� -------- <br /> Distance to_ nearest: Well -------t- 7-- Foundation <br /> SEEPAGE PIT [� Depthi __---e�---- <br /> ---- Diameter --- -�- --- Number ----._--- ---------- Rock Filled Yes <br /> i <br /> Water Table Depth ------ �0 Rock Size . j X <br /> - / I <br /> Foundation _ -- Pro Line -------------•------•- <br /> 4 Distance to nearest: Wel! ----- --- U ----t I------ p' <br /> t. <br /> REPAIR/ADDITION fPrev. Sanitation Permit# ----------------------- --- Date ---------------------------• ) <br /> Septic Tank (Specify Requirements) ------- ----------------------- --------- ----•--------------------------- <br /> Disposal Field (Specify Requirements) ------------ ----------------------------------------------- <br /> ------------------------ <br /> ------------------------------------------------------------------------ <br /> -------------- <br /> i ---------------------------------- <br /> ------ ------------ ------------------------------ -------- a <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 /> j "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 /> f as to become subject to Workman' ompensation laws of California." <br />' l''. -- Owner <br />' Signed --- - . . - ---=---=- = =---- -- <br /> / F <br /> -- ---- Title <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED By _ ----- ------__- DATE - -----------7 --------------------- <br /> BUILDING PERMIT ISSUED ------------------------- ------------------------------------------------ DATE - ---- ----- ------------ <br /> ADDITIONAL COMMENTS ------ ---------- --------------- --------------------------------------------- <br /> - ------------ -- <br /> ------------------------------------- <br /> ------------------- --------------------:----------------- -------------------------------------------------------- <br /> ----- ----- ------------------------------------------------ - ------ <br /> ------------------------------------ <br /> ------------------------------- ----------- - ----- <br /> ---- - ------------ <br /> ----- - ---------------------------------------------- <br /> Date -- ------------- <br /> ' Fina! Inspection by: .-- -- -------------------------------------------- -------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />