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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> ----------------- 17------------------------ <br /> (Complete in Triplicate) Permit No. <br /> --------------------------------------------------------- <br /> This Permit Expires 1 Year From Date Issued 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 Countyy�Ordinance No. 5/49 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION __.- -le rfe-------CENSUS TRACT _------------ ----------- <br /> Owner's Name ------ --------D-a AX-------------------- ---- ----------- /-------------Phone --------------------------••-------- <br /> Address � .� � _� ia/1------- ------------------------------------ City &7 '-'t��''-----------------------------------------...------- <br /> /' <br /> Contractor's Name ----------Q�f _ ---- - -- -------.License #Z�-x'77.---- Phone ------------------------------ <br /> Installation will serve: Residence ❑ Apartment House-E] Commercial ❑Trailer Court ;P-- — <br /> Motel ❑ Other -------------------------------------------- <br /> Number of living units:---- Number of bedrooms ___________Garbage Grinder ------------ Lot Size -------1C?40�-_______________________ <br /> Water Supply: Public System and name ----- L2-------------------------------------------------------------------------------------•---------------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,} t(1 <br /> --e----------------------------------- ------------ Liquid Depth ----- � % <br /> PACKAGE TREATMENT SEPTIC TANK' Size �--------•-•- <br /> { 7 [ <br /> Capacity J200-------- TypeP &4j;1---- Material__CB L No. Compartments -----L---__-:_.-- <br /> istance to nearest.-Well :__��_'______________________Foundation ...A?_f___-___---.- Prop. Line ---------------------- <br /> V <br /> LEACHING LINE [ No. of Lines ____�__:__________ Length,of each'iline.____ .�_r Total Len__._______._ <br /> 'D' Box Type Filter Mate`ia -Depth Filter Material ..-___/ ��_____________________________ <br /> Distance to nearest: Well ---�_�__----------- Foundation -47- ---------------- Property Line ------------------- <br /> SEEPAGE PIT [ ] Depth ---._.____-_____-- Diameter ---------------- Number ____________________________ Rock Filled Yes [] No C3 <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 /> DisposalField [Specify Requirements) -------------------------------------------------------I------------------------------------------------------------------------------ <br /> -------------- -------------------------------------------------------------------------------------------------------------------------------- --------------------------------•------------------------- <br /> ---------------------------------------- -------------------------------------------------------------------------------------------- <br /> (Draw existing and required odditian..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 /> 1 <br /> Signe ---------- - ----- <br /> -- ---------- --------------------------------------- Owner <br /> BY ----- --- -- - -- }- <br /> Title - --------------------------------------------------------------- <br /> ot er an owner] <br /> t - <br /> FOR DEPARTMENT USE ONLY <br /> ZY <br /> APPLICATION ACCEPTED BY - -- y -- -- P..+�--------------------------------------------------- DATE _._fir -----��-:.----------- <br /> BUILDINGPERMIT ISSUED --------------------------------- ------------- ----------------------------------------------------------DATE ----- -------------------------------- <br /> ADDITIONALCOMMENTS ---------------- - ------- ------------------ ---------------------------------------------------------------------------- ------=------------------------- - <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> _ w .- <br /> ----- - <br /> FinalInspection by- -- --------------------------� -•-------------------------------------------------------------------- --Date .... �_------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />