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FOR OFFICE USE:... , r APPLICATION FOR SANITATION PERMIT rr <br /> ---- ----------------------------------------------- <br /> (Complete in Triplicate) Permit No: <br /> ---------=--------- <br /> -------------------------------------- <br /> This Permit Expires 1 Year From bate Issued <br /> Date Issued <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 County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION ------hS-6 6- ---------- ------------------------------ -----CENSUS TRACT -------------------------- 1 <br /> Owner's Name ----- -------- �-------------------------------------------------.- -------------------Phone .----------------------------------- <br /> Address �S_� _ --------- f- City t <br /> ------------------- <br /> Contractor's Name _-. �' - '-` - --License # --a _ _,�IA__ Phone <br /> Installation will serve: Residence Apartment House°❑ Commercial []Trailer Court ;❑ <br /> Motel ❑Other -------------------------------------------- <br /> � 9/J--,-x---�-y�-/----- I <br /> I <br /> Number of living units:_______ 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'Q Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe X 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,] 1 d. <br /> i � ' <br /> PACKAGE TREATMENT [ ] SEPTIC TANK'[,=}� Size-------------------- o_xa- -- ------------- Liquid Depth ---X___-__:____-___:----- <br /> Material_ - <br /> Capacity _I�O�-_-- Type _ _ _ --- No. Compartments -----------------=---- <br /> r <br /> Distance to nearest: Well ___—A900-_-__-____-________Foundation ---JQ------------- Prop. Line _--. <br /> LEACHING LINE [ ] No, of Lines _---- 3_____________ Length of each line---------—9------.---- Total Lengtho_'..-_-.---- <br /> I If it Ir <br /> 'D' Box --- Type Type Filter Material ----/�I.________Depth Filter Material -------tl�___---�--2-�---------- <br /> .- <br /> Distance to nearest: Well ___.46Qd___! -- Foundation _________ Property Line. ____ ______________-___ <br /> SEEPAGE PIT [ ] Depth ____________________ Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No C] <br /> Water Table Depth --------------------------------------- --------Rock Size -------------------------------- , <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ---------------------- <br /> I <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ------------------------- -----) <br /> Septic Tank (Specify Requirements) ------------------------------------ ---------------------------- ------------------------------------------------ ------------------------ <br /> Disposal Field (Specify Requirements) --------------------------------- <br /> ------------------------ <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 /> f "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 beco subject to Workman's Compensation laws of California." <br /> r � <br /> Signed -------- �. ----- -- ---------------------------- Owner <br /> BY ----------4 ---------------------------------------------- Title ----- ----- ------- ------------ <br /> (If other than bw r) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -------------------------------------------------- ------ - ----- - -``----- . •ATE -rS_5- -------•------------------- <br />' BUILDING PERMIT ISSUED --------------------------------------------------- - ------- - -------------- : ---DATE -------- ---------------------------- <br /> ADDITIONALCOMMENTS --------------------- ------------ ---- ------------ ---- --------------- ---- ---------=------- •------------------ <br /> ----------------- ­------------------------------------------------------------------------------------------------------------- -------------------------------- -------------- <br /> ------------------------------------------------------------------------------------------------------- <br /> w = <br /> Final Inspection bY- ----------------------------------------------------------------- ---- e2 - ------..Date __.�` <br /> SAN JOAQUIN O HEAL DIS ICT <br /> E. H. 9 1-'68 Rev. 5M <br />