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-FOR OFFICE USE: /lAi� <br /> PLICATION FOR SANITATION PERMIT ~7 <br /> Permit No. <br /> (Complete in Triplicate) <br /> ---------=----------------------------------------- ---- <br /> This Permit Expires 1 Year From Date Issued Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a per to construct and install the work herein <br /> described. This application is made in compliance ith County Ordinance No. 549 and a isting Rules and Regulations. <br /> JOB ADDRESS/LO ATION .__. �_� y `-r--�IN-----'-T- --------CtNSUS TRACT __________________________ <br /> C 4� <br /> Owner's Name -C - -l.. _(a------ Com ? ---•------------ SR`?'-'S <br /> C ! Phone _ - ,� <br /> Address .. --- City <br /> ' rC '/g/.6/ City -------- <br /> Confiractor's Name ._ =. _ - /- '------------------------------------------------License #�`7- 1'� __ Phone `' ] <br /> Installation will serve: Residence [[Apartment House❑ Commercial ❑Trailer Court ;❑ <br /> Motel ❑ Other -------------------------------------------- <br /> Number of living units:.__._.___ Number of bedrooms Garbage Grinder ._-- ------- <br /> Lot Size �' ________________ _ <br /> Water Supply: Public System and name ---------------------------- --------------------- -----------------------------------------Private <br /> Character of soil to a depth of 3 feet: Sand'p,. 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.) 04 <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) 00 <br /> PACKAGE TREATMENT [ SEPTIC TANK'f ] /he <br /> ize___ _-------------- --------------------- ---- Liquid Depth -_-_________---..---,____ <br /> Capacity --------------------- Type ----- ------- Material----------- ---------- o. Compartments ---------------------- <br /> Distance to nearest: Well ------ ----- ----------------Foundation --- ----------------- Prop. Line ---------------------- <br /> LEACHING LINE [ J No. of Lines _______________________ Leeach line.-------------------- ------ Total Length _____.____-_____._......._ <br /> 'D' Box ------------ Type Filter Mal ___________________Depth Filter Material --------------------.__________---I........ <br /> Distance to nearest: Well ________ ______ Foundation __-______ ------------ Property Line ----------- ------------ <br /> z <br /> PIT [ ] Depth -------------------- Diameter ___-_____ Number _____________ __.______---. Rock Filled Yes ❑ No 0 <br /> Water Table Depth ------------------ -----------------------Rock Size ------------------------------- <br /> Distance to nearest: Well ---------- -------------------_-Foundat' n -------------------- Prop. Line ---------------------- <br /> REPAIR/ADDITION(Prev, Sanitation Permit# _.__---..--_-_--_ ___________________ Date _\_ _________________-__________) <br /> Septic Tank (Specify Requirements) -------- ----- - --------------------------------------------------------------------------•- -----------------------•--- <br /> Disposal Field {Specify Requirements) ---�--�-----j------:----------------------------------- -------------- ------- <br /> -V <br /> ------ <br /> fY- ----------- ---- <br /> d---------- ------- e----- ------- <br /> ------------------------------------------------------------- ------------------------------------- ----- <br /> (Drdw existing and required addition on reverse side) <br /> I hereby certify that 1 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, 1 shall not employ any person in such manner <br /> as to become subject to Workma ' Compensation laws of California." <br /> Signed - - -----------------------------' --------------- Owner <br /> ------------ ------------- <br /> BY - `�: � '��v Title -------- -------------------------------------------------- ----------- <br /> (If of`er than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ------- - --------------------------------------------------------------------- DATE ------r7 fl"l?"'------------- <br /> BUILDING PERMIT ISSUED -------------------------------------------------------------------------- ------------------- <br /> ----------DATE ---- -------------------------------------- <br /> - <br /> ADDITIONALCOMMENTS ------------------------------------- --------------------------------------------------------------------- -------------------------------------------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ---------------------------------------- <br /> -- - ------------- - <br /> - - --------- - <br /> Final Inspection by: --------- - ---- ---- ------------- --- ---------------------------------------- Date -�-�, - -�--------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />