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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> --------- - ---- -------- --------------------- Permit <br /> {Complete in Triplicate} Y , <br /> - -----------------------------------------r �� t <br /> €€ ( ► Date Issued,`_._ `�-- <br /> ___._.___.__.________.________.__-_______________3-_ This Permit Expires 1 Yea),From Date Issued <br /> Application is hereby madelto the San Joaquin Local Health District for a permit to construct and install the work herein <br /> described. This application Is rade in compliance with'County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION ---- CENSUS TRACT _ _` ,_______ <br /> Owner's Name Qs Ilr . Phon r �4f_ )' <br /> Address _ I9---.�. 1 -------�i -.1 --------------------------r . City _/_ I ---- -. . <br /> / I <br /> Contractor's Name 1 # --`-------------'---`-----------------------•-;'------.License #�C_ .��� Phone ------------------- <br /> Installation will serve: Residence I p trtment House❑ Commercial ❑Trailer Court ;❑ <br /> Motel <br /> • ❑ Other --------------------------- --------------- <br /> Number of living units:_/____; Number of bedrooms- -------Garbage Grinder - Lot Size _ - ________________________ <br /> Water Supply: Public System and name ------------- t -------- -------` t !°--- �-----------------------------------------------------Private <br /> Character of soil to a depth of J feet: Sand' Silt❑ Clay ❑ Peat E] Sandy Loam 0 Clay Loam C1 <br /> Hardpan F] 1 #Adobe El Fill /)Materia! i If yes,type __________________________ <br /> x i 4 <br /> (Plot plan, showing size ofto , location of system kin relation toLwe,lls, buildings, etc. must be placed on reverse side.) <br /> 3r 1 <br /> NEW INSTALLATION: (No septic tank or seep❑ pit permitted if public se is avail ble within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK' Size9f�__X-,7� _/►-_Jsf�_ Liquid Depth _�7-[�__--------------- <br /> I i W <br /> Capacity�c _!��__-__ Typ = +?__ Mbti ria�4O_ _M� No. Compartments �............. t]Q <br /> L—.. .,_______ _ a �._ <br /> Distance to nearest: Well -�Q Foundation _�0____ ___ Pro Line -------- <br /> -------: P <br /> LEACHING LINE ke""No- of Linesr _______'____ Length of each --------------- Total Length.--.Q/-P---- <br /> ` � it <br /> 'D' Box y'47's___ Type Filter Ma#erialACk_.____Depth Filter Material /_?.................................... i <br /> Distance to nearest: WeIII�Q_f____________ Foundation - . s_-_------- Property Line .---_____ <br /> .---- <br /> SEEPAGE PIT [ ] Depth ___________________ biameter ________________ Number _________________.L------- Rock Filled Yes ❑ No ❑ <br /> Water Table Depth ------ ---------------------------------------Rock Size ------------�. <br /> Distance to nearest: Welli__-------------------- <br /> -------------.----Foundation_---------_--- --_,Prop. Line ---------------------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit#._..____�.r__._:,.____ ,___ :__ _L__ Date __________________ �________- <br /> Septic Tank (Specify Requirements) i <br /> Disposal Field (Specify Requirements) ------------------------------------------------------------------------------ -------------=--------------------------------------- <br /> ------------------------------------------------------- ----------------------------------------------------- <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 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 /> Signed ------ -------------------------- Owner <br /> BY Title Qr A '------------- <br /> (If other than owner) <br /> ��--�j FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -----1 h` --------------------------------------------------------------------------- DATE ------------�---,7Z ,, <br /> BUILDING PERMIT ISSUED -------------- <br /> __DATE ------------------------------------------- <br /> ADDITIONALCOMMENTS ------- -- ---------------------------------------- ---------------------------------------------------------------------------------f----7-- <br /> ---------------=--- <br /> -------- <br /> - <br /> -- - ---- -------------------------------------------------- -------------------------------------------- <br /> ------- ----- <br /> Final <br /> --=Final Inspectio <br /> Date <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT i <br /> E. H. 9 1-'68 Rev. 5M <br />