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A f <br /> FOR OFFICE USE: <br /> t� APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit No: <br /> ---------------------------------------------------- - Date Issued <br /> This Permit Expires 1 Year From 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: t <br /> � <br /> JOB ADDRESS/LOCATION .------I_: _ ,--- --------------- f-!�/ -'-- ENSUS TRACT ----------------_------- <br /> Owner's <br /> --------------- ------ <br /> (N!-1 l ---- m --------4-'a-1-------------------.--------------- -----------------:-------------------Phone -- --------------- <br /> Address <br /> - - - <br /> Owner s Name __.___ . ��i / r -- - - - - <br /> Address -- Cit N. _ _ �1_ -------------------------------------------- <br /> I g 11r�r�/ Ilett y <br /> Contractor's Name ��-------------=-=--------LicensePhone <br /> Installation will serve: Residence Apartment House ❑ Commercial -❑Trailer Court ;❑ <br /> Motel ❑ Other -------------------------------------------- �/� <br /> Number of living units:--___�--_ Number of bedrooms ---3----Garbage Grinder ------------ Lot Size -�7 ------------- <br /> Water Supply: Public System and name -----------------------------------_---------------------------------------------------------------------------Private W <br /> Character of soil to a depth of 3 feet: Sand 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.) I <br /> NEW INSTALLATION: {No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] Size:_ �j� ,? �__C7____ _______ Liquid Depth _ ___________- I <br /> Capacity f--�__d_. Type ________- Material No. Compartments _�.,..____-_-...-- <br /> Distance to nearest: Well ----- --------------------Foundation ---------- Prop. Linen __________-....__ <br /> LEACHING LINE [ ] No. of Lines ____s7 --------------- Length =----ne.___ ____ Total Length c�o------------- <br /> De c <br /> D' Box ___ ___.__ Type Filter Material ________________ Depth Filter Material _ /--__________._____ <br /> Distance to nearest: Well ------------------------ Foundation ________________________ Property Line ---------.-------------- 1 <br /> z SEEPAGE PIT [ ] Depth -------------------- Diameter _______________ Number ---------------------------- Rock Filled Yes ❑ No i❑ <br /> WaterTable Depth ------------------------------------------------Rock Size ---------------- -------------- <br /> Distance to nearest: Well ----------------------------------------Foundation --------------------- Prop. Line ---------------------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ____________________________________________ Date ---_________________--__________-) !Q <br /> 7 <br /> SepticTank (Specify Requirements) ---------------- -------------------------------------------------------------­­---------------------------------------------------------- <br /> DisposalField (Specify Requirements) ---------------------------•----------------------------------------------------------------- ----------------------- - --------. <br /> ------------------------------- -- --------------------------------------------------------------------------------------------------- -------------------------------- <br /> T <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 Workm 's Compensation laws of California." <br /> Signed ---- -- ------ ------------------'-- -------------------- Owner <br /> By ------ ---------- ------ ----------- ------ -------------. Title --------- -------------------------------------------------------------- <br /> (If other than owner) <br /> R .DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ____________ _ ------------------------ DATE __$'`_-��.-_�rj—._---------- <br /> BUILDING PERMIT ISSUED ----------------------------------------------------L--- -- <br /> ---------------------------------=--------------DATE ------------------------------------------ <br /> ADDITIONALCOMMENTS - ---- ---------------------------------------------------------------------- ----------------------------------------------------- -------- ------------------ <br /> -------------------------- <br /> •---------------- <br /> --------------------------=------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ------------------------------------- ---- ------------------------- ----------------------------------------------------------------------- -----------------------------/ _-_�_---------------- <br /> --------------------------------------------- ---V <br /> --- - -- ------------- <br /> Final Inspection by: - - -ate <br /> �- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M � <br />