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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> ----------------------------- ---- p p Permit No: <br /> (Complete in Triplicate) i <br /> -------------------------------------- <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 ade-in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION ------ �`� T'r'y''^'` Tmci ---L3wo--------------CENSUS TRACT -------- <br /> Owner's Name ---------------------r- -----I ? 5K---------------------------------------------------•-- ------Phone ------ ---------------------------- <br /> Address ----- --------UP-j4(a----- 61i,,.S0S_TvV-- Rq---------------------------------•--. City ----------------------------------- --------------------------------- ...... <br /> Contractor's Name ----- ---15--f,4P-L�- 0_JN ------------------------------- --------License # 9-50P�------- Phone _63-S---8 f ----•-- <br /> Installation will serve: Residence Apartment House❑ Commercial ❑Trailer Court ;❑ <br /> jj Motel E] Other -------------------------------------------- <br /> Number of living units:___-1.-_-_ Number of bedrooms -----3....Garbage Grinder A6----- Lot Size _/ __ __t4 ---_------__-_-_ <br /> Water Supply: Public System and name ----------------------•---------------------------------------------------------------------------------------Private <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay .❑ Peat❑ Sandy Loam 0 Clay Loam ❑ <br /> Hardpan ❑ Adobe E�t­Fill 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 joT' ((�'� ,,,, Siz��e-----------2 --------------------------- Liquid Depth ---��-----_-------_-_ � <br /> Capacity _. __-_ Type R9_& rr----- Materia l_QrYKJ? ------ No. Compartments ------2-_ <br /> Distance to nearest: Well --------- ------------------Foundation --------/P--------- Prop. Line 6.15 ---__---____ <br /> LEACHING LINE [ ] No. of Lines --.-_--�)-------------- Length of each line----- �C4------_------- Total Length ,. _ ...----_----- <br /> 'D' Box `9_--- Type Filter Material _1 --___Depth Filter Material ---------- _-------------------- <br /> Distance to nearest:.Well ------------- Foundation ......P-0----------- Property Line ------ __-------__ <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No i❑ <br /> WaterTable Depth ------------------------------------------------Rock Size ----------------------- ------ <br /> Distance <br /> ----- <br /> Distance to nearest: Well ----------------------------------------Foundation ------------------_---Prop. line ----------- ........ ' <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date -------------------_-__-----------) 1V <br /> SepticTank (Specify Requirements) ------------------------------------------------------------------------------------------------------------------------------------•---••- <br /> Disposal Field {Specify Requirements) ------------------------------------------------------------------------------------------------------------------------------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ----- ------------------------------------------------------------------------------------------------------ -------------------------------------------------------------------- ---- ----------------- <br /> (Draw existing and required addition on reverse side) <br /> 1 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 beco subject t ork an's Compensation laws of California." <br /> Signed ---------- Owner <br /> - ---------------------- Title <br /> (If other than owner) <br /> FOR DEPARTME T USE O LY <br /> APPLICATION ACCEPTED BY - DATES¢ p� <br /> BUILDING PERMIT ISSUED -------------------------- - ---- -- =-------DATE ..------------------------ -- <br /> - ------------- -------- --------------------- - <br /> ADDITIONALCOMMENTS -------- --------------------------------- -- -------------------------- ---------------------- ---------------- - ---------------------------------------- <br /> --------- -- --------------------- <br /> ----------------------------------------------------- ---------------------- <br /> ------- ------- -- ----------------------------------------------------------------------------------- yy ----------=------- <br /> Final Inspection by: ---------------------------------- ---------------------- '! [ Date _" f'-2 -- ---- <br /> SAN JOAQUIN LOCAL HEALT D1S7RICT ��yy <br /> E. H. 9 1-'68 Rev. 5M kA(7 '' <br />