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FOR OFFICE USE: <br /> APPLICATION FOR. SANITATION PERMIT <br /> - --------------------- <br /> - Permit No: <br /> (Complete in Triplicate) <br /> --------------------------------------------------------- This Permit Expires 1 Year From Date Issued <br /> Date Issued ---a 7 <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 /> S' <br /> JOB ADDRESS/LOCATION ---------------------------------------------------------` <br /> . 19�y� CENSUS TRACT <br /> ' <br /> J - <br /> - <br /> k� �jOwners Name _ �. <br /> tyt N-------------------------- ---- --------- <br /> --- <br /> Address g/ ---------------------------------- <br /> 1Contractor's Name _._ / --------------------License #arJll�--- Phone --.... =---....- <br /> Installation will serve: Residence ❑ Apartment House❑ Commercial ❑Trailer Court i❑ <br /> Motel ❑Other -------------------------------------------- <br /> Number of living units:----_f-_- Number of bedrooms __,i7_:__-Garbage Grinder ------- Lot Size ---_______-_____________________________ <br /> Water Supply: Public System and name -------------------------------------------------------------------------------------------------------------Private ER <br /> Character of soil to a depth of 3 feet: Sand 6 Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan❑ Adobe ❑ Fill 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[ ] ize____________________ _____-_---- ------------ Liquid Depth ----------..-_.-_--_______ 6 <br /> Capacity - ----------------- Type ------- ----------- Material --------------------- No. Compartments ---------_-- ....... v✓ <br /> Distance to nearest: Well ___ ---------------------------- _Foundation ----- ---------------- Prop. Line -___-__-__..______.___ <br /> LEACHING LINE [ ] No. of Lines ------------------------ ength of each 1' e---------------------------- Total Length ----------- ................ <br /> 'D' Box -------- --- Type Filter Material ------------ ------Depth Filter Material -___----___--__---.---_____-_-____--_.--_- <br /> Distance to nearest: Well ------------------------ F ndation ------------------------ Property Line ------------_---_--- <br /> SEEPAGE <br /> ---__-- _--_.--___SEEPAGE PIT [ ] Depth -------------------- Di meter ---------------- umber --------..------------------ Rock Filled Yes '(] No C] A <br /> Water Table Depth ---------------------- --------------Rock Size --------------- ------- ------ <br /> Distance to nearest: ell ---------------------- _-___-___,_---Foundation ------.------------- Prop. Line ................. p� <br /> REPAIR/ADDITION(Prev. Sanitation Permit - ------------- - -_ --__------ Date ----------------------------------) <br /> s <br /> SepticTank (Specify Requirements) ------ ----------- ---------------- --------------------------------------------- --------------------------------------------------------- <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 /> ----------------------- <br /> B - � --''� ----- T -- <br /> Title ----------- <br /> By <br /> other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ----------- --------------------------------------------- DATE --- -�f <br /> ! - <br /> BUILDINGPERMIT ISSUED --- -------------------------------------------------------------------------------------------DATE ----------------------------------- <br /> ADDITIONALCOMMENTS ------------------------------------------------------------------------- ------------------------------------- ------------------------------------ <br /> ---------------------------------------------------- ------------------------------------------------------------ ------------------------------------- ------------------------------------------------ <br /> ---------------------------------------------------------------------------------- --------------------------------- <br /> - ------------------------------------------------------------------ ------- <br /> - =------- - - - - - <br /> Final Inspection by: ------------ < Date 'A -'`� _ <br /> ------- - -- -- ------------------•- <br /> ---�� <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT C� <br /> E. H. 9 1-'68 Rev. 5M <br />