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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> Permit No: <br /> ------- - ----------------------- --------------------- <br /> - • <br /> (Complete in Triplicate) <br /> This Permit Expires i Year From Date Issued <br /> Date Issued/-/ <br /> _ _ � . <br /> ------------- -- ---------------------- -------------- <br /> .I <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 /> i <br /> JOB ADDRESS/LOCATION �-��----,/��_ ---�C's�� - ----- --- � � --..CENSUS TRACT --------------•----------- . <br /> jl vv a <br /> Owner's Name d --- ' '//-�tJ ---------------------------------------------- -------- ---------Phone ------------------------------------ <br /> Address ------- ---- ---------- - ---------------------------- »^_t_ — <br /> Contractor's Name �1 _' � - -- ------ - - ---------License #��//G�P2Phone <br /> l/ <br /> Installation will serve: Res}denceAApartment House❑ Commercial ❑Trailer Court ;❑ <br /> F Motel ❑Other ----------------------I--------------------- <br /> I <br /> Num`bdr of living units':---- Number of bedrooms "_Gardage.Gr..inder... 4,t 0_ Lot -------------- <br /> Water Supply: Public System and name ---------------------- ___.-------------------------------------------------------------------------.Private <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt F1Clay E] Peat❑ Sandy Loam .Q Clay Loam Xf <br /> HardponpS Adobe ❑ "Fill Material ----- ------ If yes,type ------------------ ------ <br /> (Plo'plan, showing' size of lot, loco on`of system in relation to wells, buildings, etc. mus4e placed on reverse side.) <br /> NEWi r A r , <br /> INSTALLATION--,(No septic tank or seepage pit permitted if public sewer is available within 200 feet) <br /> � Depth ------------[ ] SEPTIC TREATMENT Size--------tI------------------------- Liquid` }-� <br /> ,s <br /> i Capacit ------------------- Type Material{ No. Co Ppartmenfis --- r <br /> t ► ' �� Pro <br /> Distance to nearest: Well ___-________--------------=-------Foundation ___-- •------------ p. Line ---------------------- p <br /> sJ k't <br /> LEACHING LINE P [') No. of Lines ________________________ Length of each line_ ___.--r_.-' ---- Total Length --------------------------- to <br /> I <br /> D' Box Type Filter Material ___--------------- Depth Filter Material -------------------------------------------- t <br /> r <br /> l`rf <br /> Distance to nearest: Well -------------------�-"---Foundation -------------------- -- Property Line. ------------.----------- . <br /> SEEPAGE PIT [ ) Depth DiameterNumber ------------ --------------- Rock Filled Yes '❑ No I❑ <br /> Water Table-Depth <br /> -- ---- ---- <br /> �._.__�. ..,.W....p.,... . Rock Size -------------------------------- <br /> Distance to nearest: Well _____________ __________ ______ ___ <br /> --Foundation -------------------- Prop. Line --------------------- '! <br /> 000, <br /> REPAIR%ADDIT,ION(Prev. Sanitatiom Permit# --------------------- --------- --- Date ------------------ '` <br /> ------------`--) <br /> Septic Tank {Specufq Requirements) ------------------------------------------ ---------------------------------------------- :--------------:••----------------- <br /> / <br /> Disposal Field (Sped-yN quirements) -_- <br /> J '-------------------------------------------------------------------------------------- - r <br /> ---------------------------------- ----------- --- <br /> ------------------------------------------------------------ ----------------- ------------------- <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that I have prepared this applicat on and that the 'work will be done in accordance with Sart 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: ! t <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 .------------------- - - -------- —e------------------ Owner <br />' B -- ---1-------------------- Title . -- ��e_:741 - --------------- --------- <br /> Y <br /> (If of t an owner) Ilk <br /> FOR DEPARTMENT USE ONLY <br /> /�� <br /> r APPLICATION ACCEPTED BY - -- ----- ---- --------------------------- ------------------ --------------------- DATE ---7--------------- <br /> " <br /> BUILDING PERMIT ISSUED --------------- -------- - -------------;--- ---------DATE ---------- ..... ------- -------------- <br /> ADDITIONALCOMMENTS ---------- ------- ---------------------------------------------------------- ----------------------------------------------------- ------------------ -------- <br /> ---------------------------------------------------- <br /> --------------------------------- -------- _ _ - _ _ _ -_ <br /> --- ------------------------------ <br /> --------------------------- - ------- D -/ <br /> Inspection by: ate ' -- ------ -------- <br /> Final = <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />