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FAR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> -"--------- ----- ----- -------- ---- -------- Permit No. -- -- •- � <br /> (Complete in Triplicate) <br /> ----- ------------------------- 2-7 <br /> Date Issued --.----"Z- <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: <br /> JOB ADDRESS/LOCATION - ---- -------------------------CENSUS TRACT �6�, 1--�rt C—' <br /> Owner's Name ------PnX-_r5_i A-ie----- <br /> tt - ' Phone !V- <br /> --Address -------- ------------------------------ City -------- ----rA/W---------------------------------.-.----- <br /> , <br /> Contractor's Name,o ---License #JQ.-C <br /> .... <br /> --9 Acf'� �-- Phone -- <br /> Installation will serve: Residence Apartment House-[] Commercial ❑Trailer Court ',❑ <br /> Motel ❑ Other ------ -------------------------------------_ - / <br /> Number of living units:-----I------ Number of bedrooms ----- _Garbage Grinder ---------- Lot Size ..--/_--�_ --••- <br /> Water Supply: Public System and name ---------------------------------•-------------------------------------•-------------------------------------.-Private ❑ <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.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK Size----- ��_'Y ___ ----- --.�- Liquid Depth _-Jif------------ <br /> Material__�Qf1C��P.- No. Compartments ___ ---- ---. <br /> Capacity fU U--- Type p <br /> i <br /> Distance to nearest: Well -- ____�__--a--------------Foundation _--_��__________ Prop. Line ... ..._�_-_------ <br /> LEACHING LINE ] No. of Lines -------�---______._ Length of each line-------- r-1_._�__ Total Length -- _`e............. <br /> 'D' Box -----/----- Type Filter Material ----2 "----.Depth Filter Material ----------- ----------------------------- <br /> Distance to nearest: Well ------- Foundation ...... Property Line ---- _.�----- <br /> SEEPAGE PIT [)(j Depth ---. t _ --- DiameterNumber -----------0------------- Rock Filled Yest No i❑ <br /> Lv / ' <br /> Water Table Depth -------------� -------------------------Rock Size ------�--------------------- <br /> Distance to nearest: Well ./ ?Q--- -------------------Foundation .0 ---- Prop. Line ----- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------•--- `--------------------- Date _--_------_----_-----...__-_-_--..) <br /> Septic Tank (Specify Requirements) ----------------- --------------- - - ---------------------------------•---------------------------- <br /> Disposal Field (Specify Requirements) ------------------------------------------------------------------------------------------------------------------------ <br /> ----------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------- <br /> -------------------------------- ---- -------------------------------------------------------------- --------------------------------------------------------------------------- ------------------------- <br /> (Draw <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 ------- ------ ------ ------------------------ --- <br /> (If other than owner) <br /> FOR- DEPA- USE ONLY <br /> APPLICATION ACCEPTED BY . DATE --- - ----- �/ --------------- <br /> -•-------------------------- -------- <br /> BUILDING PERMIT ISSUED ------------ -------------------------------------- DATE - <br /> ADDITIONALCOMMENTS -- -------------------------------------------------------------------------- --------------------------------------------------------------- - ----------- <br /> - ---------------------------------------------------------------------------------------------------------------- --------------------------------------------------------- -- ----------- <br /> . l `-- - <br /> Final Inspection b 1 ------------------------------ --------------------------------------------------------- <br /> -- --- -----------------------------------------Date -1 <br /> P Y ��? iy,�? ------------ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />