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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PER <br /> MIT <br /> (Complete in Triplicate) <br /> ------------------- ------------------ <br /> f - ,/ 7-y�/ �' <br /> j Date Issued 7�=-------------- <br /> - r <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 AQDRES5/LOCATION ---- -' --- 17--------,�J C i c/ --- ---------CENSUS TRACT - 3 --------------- <br /> Owner-'s Name ------------ _uC..S-------------------------------------------------------------------------------------------------Phone --=--------------- ----------------- <br /> " Address <br /> ---------------- ?----- ------ -----G``{`----------------- City - -1 -- --------------------------- <br /> Contractor's Name _ !710------- d� _ � _--_.License # ,O ; Phone <br /> Installation will serve: Residence-ffr-Apartment House-0,Commercial-[]Trailer Court i❑•- - <br /> Motel ❑ Other ------''------------------------------------- <br />' Number of living units:---------f-- Number of bedrooms _________Garbage Grinder.<�1__6?____ 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 n Adobeill Material w__('__ If yes,type ____________________________ <br /> a <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 aJa�ila�le.witlhin-.200 feet,) ' <br /> PACKAGE TREATMENT <br /> [ ] --------------------------------------- ------- Liquid Depth --•--------------•--------- .. <br /> [ ] SEPTIC TANK� Size <br />' Capacity ------------------ Type -------------------- Material----------------- No. Compartments '.-----------------= V : <br /> Distance to nearest: Well ____________________________________Foundation ---------------`�:t-Prop, Line ........................ ; <br /> LEACHING LINE [ ] No. of Lines ------------------------ Length of each line_ _________________________ Total Length .................... <br /> 'D' Box ------------ Type Filter Material --------------------Depth filter Material ----------------------- .................... <br /> Distance to nearest: Well ______________ Foundation ------------------------ Property Line. __________________._____ <br /> SEEPAGE PIT [ ] Depth -------------- ---- Diameter ______________ Number ----------------------- Rock Filled Yes ❑ No <br /> Water Table-Depth ------ ----------------- _-=--=-Rock.�Size -------------------------------- <br /> Distance to nearest: Well ________________________________________Foundation ____________________ Prop. Line _._________.____-____- <br /> REPAIR/ADDITION(Prey. Sanitation Permit# _____________________________ ------- Date _____________________:____________) <br /> Septic Tank (Specify Requirements) ------------------ -------------------I--------'-------------------------------------------- --------------------- <br /> Disposal Field (Specify Requirements) __ r'___-Cis- "-.".__ __ -C�___--___ -s ---------------- --------------- <br /> 3 3 - ---�---------ma c N-= -----4 --i-leA-------------------------------------------------------------- <br /> .. ------------------------------------------------'-'----'----------------------------------`__- ---------- ------------------------------ - <br /> " (Draw existing and req.iiired-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 /> "1 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 ------------------ --- Y C'� ---"-------------------------- Title <br /> (If o er t an owner) <br /> O FOR DEPARTMENT USE ONLY + <br /> APPLICATION ACCEPTED BY --- ' "i.-�tDATE -a n`.r <br /> ----- ----------- - l <br /> BUILDINGPERMIT ISSUED ------ ---------------- -------------------------------------------------------------------------DATE ---------------------------------------- -- <br /> ADDITIONAL COMMENTS - t <br /> -------------------------------------------------------------- <br /> ------------------------------------------------------------------------------------------------------------------------------------------- i <br /> -------------------------------------------- <br /> ------- --- - - ------- ----- <br /> ------------------ - -- ---------------- ------ ------------------------------------------------ <br /> Final Inspection by: -----• ------- ---- -- -------- - - ------- -- <br /> ' Date 1 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'b8 Rev. 5M <br />