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FOR OFFICE USE: <br /> 4-) - - --- ---- ------ ---- --- - APPLICATION FOR SANITATION PERMIT <br /> ID <br /> --------- ---------------- (Complete in Triplicate) ermit No. <br /> -.------------------ SCANNE6 <br /> -—------------------------- This Permit Expires I 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 compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> J013 ADDRESS/LOCATION , !Y-L V,9 <br /> ------------- <br /> ------------ -- ----- <br /> Owner's Name 44", CENSUS TRACT --- <br /> Address '17 ------------__----- --7--- -- --------- ------ <br /> Za 0�----- City - ---- -------Phone -----------------­-------I--------- <br /> Contractor's Name ---- --- - ----- - ----------- --------------------------------------- <br /> Installation will serve: ----- ----- --- ----- License # -- --- _ -------------- Phone --.--_--__----------------- <br /> Residence <br /> ED Apartment ouse,E] Commercial []Trailer Court C] <br /> Number of living units:.. Motel [_] Other --- <br /> -- ------------ <br /> Number of bedrooms --_------.-Garbage Grinder Lot Size --- <br /> Water Supply: Public System and name - -- ------ --- -- - ------------- -------- -- ---- - ------ ----------- --------------- --- --------------Private E]----------- <br /> Character of soil to a depth of 3 feet: Sand [] Silt[] Clay [] Peat❑ Sandy Loam 0 Clay Loam El <br /> Hardpan 0 Adobe El Fill Material __ - Ifyes, 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-____----_----_----- <br /> ----Capacity Type Material_...__..__._..- Liquid Depth -------------------------- <br /> Distance to nearest: Well ----- ---- No. Compartments _..................... <br /> LEACHING LINE No. of Lines . --------------------Foundation ---- - ---- Prop. Line - -------------------- <br /> - Length of each line Total Length ---------------------­----- <br /> 'D' Box Type Filter Material ---._------_.-----Depth Filter Material - ------------ -----­--------­--- <br /> Distance to nearest: Well - - ----- - ----- -- Foundation ---------I— - -- Property Line <br /> ---.'.....-....--'------ <br /> SEEPAGE <br /> --- ...... .......SEEPAGE PIT Depth ------ Diameter ---------------- Number -- - --------------- --- Rock Filled Yes [3 No 0 <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 /> Disposal Field <br /> 'y (Specify Requirements) --- -1,14 . .......Z- - 7- ---- ale- -- - "-str.710 <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 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 sign6ture 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 ------------ --- -------------------------- Owner <br /> By a nowner) <br /> ------ ----- ------ . Title ------- - - ---- <br /> (If <br /> OF Z FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -, - - <br /> ---------------------------- , DATE --------------------- <br /> BUILDING PERMIT ISSUED - ------- --------------------------------------------------------- --------- --------- ---DATE ------------------------------------------- <br /> ADDITIONALCOMMENTS , ------------------------------ --------------------------------------- ------ ------------------ - ----------------- ----------------- --------- <br /> -------­------------ -- ----- ---------------------------------------------- ------------------I ------------- ---------------------------------------------- ---- -- <br /> -------- <br /> -- - --- -- -- -- -- ----- ----------- ---- - ------ -- ----- --- ------------------------------------------- ---------------------- -------- <br /> - ---- -- --- - - - -------- ------- --- ------------ <br /> SAN <br /> ------------------- <br /> - <br /> Final Inspection M - - - <br /> - - ---- - - - <br /> - . . ---- ---- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />