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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> $—/ <br /> ----------- ---- Permit No-. __ `/:" <br /> (Complete in Triplicate) ----- <br /> -------------------=----------- <br /> This Permit Expires 1 Year From Date Issued <br /> Date Issued <br /> -- <br /> ---------------------------------------- --------------- <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 /> JOB ADDRESS/LOCATION --------CENSUS TRACT ._.__�_'............. <br /> Owner's Name - 'Ef- --- Phone X.Z <br /> ' ---------- <br /> Address <br /> ? <br /> Address --------- �-/ ST�� S --. . <br /> City� /!✓T <br /> Contractor's Name . X. f� e---- 3 =--------Licensees- <br /> -- Phone :_ ®S� <br /> Installation will serve: Residence P.4artment House❑ Commercial QTrailer Court i❑ <br /> Motel ❑Other -------------------------------------------,�,,� <br /> Number of living units:--/______ Number of bedrooms --- --_-Garbage Grinder✓ ____ Lot S. -----. e lqe-- ------------ <br /> Water Supply: Public System and name ----------------------------------------------------------------- -•---------- --------------------------------Private <br /> Character of soil to a depth of 3 feet: Sand'[ Silt❑ Clay ❑ Peat❑A, Sandy Loam Q Clay Loam;Q <br /> Hardpan ❑ Adobe'Q 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,) \t <br /> PACKAGE TREATMENT [ I SEPTIC TANK f ] Size------------------------------------------------ Liquid Depth _____.____---.------.--- "1 <br /> Capacity ----------------- Type -------------------- Material---------------------- No. Compartments ----------- ------ <br /> Distance to nearest: Well --------------------------_---------Foundation ---------------------- Prop. Line __..._.__.,... ........ <br /> LEACHING LINE [ ] No. of Lines ------------------------ Length of each line---------------------------- Total Length --------- --------- <br /> 'D' Box ------------ Type Filter Material ____________________Depth Fitter Material --------------------.......................... <br /> Distance to nearest: Well ________________________ Foundation ------------------------ Property Line ........................ <br /> SEEPAGE PIT [ ) Depth ____________________ Diameter ---------------- Number ---------------------------- Rock Filled Yes '❑ No <br /> Water Table Depth ----------------------------- ----- ------.Rock Size -------------------------------- <br /> Distance to nearest: Well ________________________________________Foundation -------------------- Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----__--_-_.--..-___---.____-_.-__) <br /> SepticTank (Specify Requirements) --------------------------------------------- ---------------------------- -----------------------------,---------------------------- <br /> Disposal Field (Specify Requirements) pCv __� 4'jj®_v'T_P_ _. !Q -- ��✓ --- ------------- <br /> ------------------------------------------------ ® Q - '�''�° '' i ' <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 /> "1 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 bebject to cman's Compensation laws of California." <br /> Si ne co subject <br /> --------- -- ------------------------------------------ Owner <br /> Al- <br /> BY r- t --------- Titlex" J <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> }. - f" ' 6 <br /> APPLICATION ACCEPTED BY---_`_'F--�-R-` -----------------------------------------------------7Z---- <br /> -----• DATE ---- ----------------- <br /> BUILDING PERMIT ISSUED --------------- DATE <br /> ADDITIONALCOMMENTS --------------------------------------------------------------------------- -------------------------------------------------------------- --------------------------- <br /> ----------------------------------- ------ - ----------------- --- --- --- - ------------------------ --------------------------------------------------------------- <br /> ----------------------------------- ---- ------------------- ------- ------------------------------------- / �.Z = <br /> Final Insp tion by: •-- ----------------------------------------- Date ---- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />