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_ t <br /> FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> --- --------------I------------- Permit No. <br /> ---------------- (Complete in Tri <br /> ----------------------------_--_------------ This Permit Expires 1 Year From Date Issued <br /> Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein 1 <br /> described. This application i/s/fmade in compliance with County Ordinance No. 549 and existing Rules and Regulations: , <br /> JOB ADDRESS/LOCATION .l -lf �-- - -----CENSUS <br /> ' ++ � <br /> 6 <br /> " T---------------------------------- <br /> RACT -_--------- <br /> PhoneOwners Name wq--"-R- ------�------ <br /> Address ---- City � ------------------------'-------------••---.--- <br /> 3, <br /> Contractor's Name . •---------------- --------- -----------------------------.License # ---------:-------------- Phone ----------- ----- <br /> Installation will serve- Residence,] Apartment House❑ Commercial :❑Trailer Court [] <br /> Motel ❑ Other ------------------------------------- ,� �� <br /> Number of living units:---- _____ Number of bedrooms __________Garbage Grinder ------------ Lot Size _�/__7�,�- <br /> `- r <br /> Water Supply: Public System and name ----------------- ------------------------------------------------------•---- --------Private <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat❑ Sandy Loam jE Clay Loam 0 <br /> Hardpan ❑, Adobe ❑ Fill Material ------------ If yes,type ---------------------------- {, <br /> (Plot pian, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) t' <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 /> NA <br /> Capacity -------------------- Type -------------------- Material---------------------- No. Compartments --------------------- <br /> Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ----------------..... <br /> - <br /> LEACHING LINE [ ] No. of Lines ________________________ Length of each line---------------------------- Total Length -----------._____---___-___. <br /> 'D' Box -------- --- Type Filter Material ___________________Depth Filter Material --------------------------- ---------.----.- <br /> Distance to nearest: Well ________________________ Foundation ________._______------ - Property Line ----------------.------_ <br /> SEEPAGE PIT [ ] Depth ____ _______________ Diameter _______________ Number ----------------- ---------- Rock Filled Yes ❑ No .i❑ <br /> WaterTable Depth ------------------------------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well ________________________________________Foundation --------------- ---- Prop. Line .._.______..__-_.___-- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# •------------------------------------------- Date ----------------------------------I <br /> Septic Tank (Specify Requirements) ---------------------------------------------------------------------------------- <br /> 3 <br /> -------------------- - <br /> � <br /> Disposal Field (Specify Requirements) <br /> ---ea�� �' ---------= �'� r� "¢ t j s' -r --'---------------- ------- <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, 1 shall not employ any person in such manner <br /> as to beco eVsuctma ' <br /> to Wor - , Compensation laws of California." <br /> Signed �l Owner <br /> By---------------------------------- �. --------------------------------- Title <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY _-Z._1 I--------d-�-----------------------------------------------------------. DATE ---•-------•----------- <br /> BUILDINGPERMIT ISSUED ----------------------------------------- ---------------------------------------------------------------DATE ------------------------------------------- <br /> ADDITIONALCOMMENTS ---------------------------------------------------------------•--------------------- -----------------------------------.---------=----------- <br /> -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> --------------------------------------------------------------------------------------------------------------- <br /> -------------------------------- ----- ---------A----------- -------- --------------------------------------------------------------------- �f <br /> Final Inspection by. / ��'' ----------------------------------•------------------------ --------------Date�.1-___/- -----r l _----------•------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev, 5M <br />