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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> JO_'d-0 �_7�� <br /> -- ---- ---- ------- {Complete in Triplicate) Permit No. - <br /> ------------------ -------- ---------- --------------- $ <br /> ------- This Permit Expires I Year From Date Issued Hate 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 CouJ�ty Ordinance No. 549 and existing Rules and R ulations: <br /> JOB ADDRESS/LOCATION '= ///��--------------------- ----------------CENSUS TRACT --------------•----------- <br /> �^^—Owners - _-- ---- `--------------------- --------- RPh-one <br /> Address --------------------- -- - ---- - �----- - City =-- <br /> 1 ' <br /> Contractor's Name ------- --------License # --- Phone '------------------------------ <br /> Installation <br /> hone '------------------------------ <br /> Installation will serve: Residence ' Apartment House°0 Commercial ❑Trailer Court ❑ { <br /> � r <br /> Motel ❑ Other -------------- <br /> vNumber"of bedrooms ___ ____ fi // ~ <br /> Number of living units:------------ __Garbage GrindeA�d_.-_. Lot Size .------ _ /_S__0______ <br /> WaterSupply: Public System and name _ _______.__________ I Private ❑ <br /> --------- -- <br /> I t it k, 1. l ' .. v fti i M <br /> Character o€ soil to-'a depth'of:'feet:1 S'nd'❑ Silt Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ AdobeFill Materia! .----------- If yes, type _____ -------- ------- <br /> # 1 I <br /> (Piot plan, show.ing_size-of_lot,,.location of system in relation to wells, buildings,..,etc., must be placed on reverse side.) <br /> I �ry f f y i __ T .. . - -{ <br /> NEW INSTALLATION: (No septic tank or seepage pit p�matted if public sewer is available within i200 feet) <br /> I t If <br /> PACKAGE TREATMENT [ ] SEPTIC TANK'[ ) N j,� �' Size_------------ ----i I--.-- ----- ---------- Liquid Depth ---------------_ ---------- r. <br /> Capacity ----------- -------- Type ____- ------ _----- Material_---I _____ ------- No. Compartments ---------------------- <br /> Distance to nearest: Well ________. __.__�_ A----------Found aonw +-f __ -- -_ Prop. Line ______________________ J <br /> Total Leng4 ---._______. <br /> LEACHING LINE [ ] No. of Lines ___ ___ _ ________ _._ Length of eaoA'line�?=_____ � g <br /> D' Box -----------I Type Filter Material -------------— Depth �#jljer, Materia! ------_------ <br /> -------------- <br /> ------------------------ i <br /> Distance to nearest: Well ------------------------ Foundation --------.--------------- Property Line. ------------------------ <br /> S - <br /> SEEPAGE PIT [ ] Depth ------------ -----__Diameter ------ Numberr ____________________________ Rock Filled: Yes EJ No ❑ <br /> Water Table Depth -J--/--------------- ---------------Rock Size -------------------- <br /> V . <br /> Distance to nearest: Well --------u -------------------------Foundation -------------------- Prop. Line _------.------------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ---------------------- -------------- Date ---------------------------------- <br /> Septic Tank (Specify Requirements)_ ___ �__ j <br /> ------------------------ <br /> - ------ ----------------- <br /> Dispo sal ield (Specify Re iremennttjs) - -------:---- - ---- --- -- -- --- - ----------------- <br /> ` - �` `f/` � ' r -- r` ------------------------- ---- ------------------------ <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)t State laws, and Rules ,and Regulations of the. San Joaquin Local Health District. Home owner or licen- <br /> sed agents'sign6tu7e certifies the fol{owing"r <br /> "I certify that in the performance}f the work for which this permit is tissued, 1 shall not employ any person in such manner <br /> as to become subject to Workman s Compensation laws of California.y' j <br /> Signed ---------_ Owner <br /> By - - ------- 0.= *� Title <br /> (if other n_owher)� <br /> # E FOR DEPARTMENT.USE ,ONLY... <br /> APPLICATION ACCEPTED BY ' DATE ------- ------------- <br /> BUILDING PERMIT ISSUED --------------------- ------ ---------------- ----DATE ---------- -------------------------------- <br /> - -------------------------------- <br /> ADDITI'ONAL COMMENTS -- -- ----------------------- -------------------------------------- --------------------------------------------------------3 ------------------- ------- <br /> ' ------------------------------------- -------------------��-- = -F_�_ ------------------------------------- <br /> ----------- - -- ---------.,----------- l ---- <br /> --------------------------------------------- <br /> --- <br /> --------------------- , <br /> {� - ----------------------------------------------------- - - - - - ------- <br /> Final Inspection by= �� -Vd"-P--------- ----------------------------------------------------------------------.Date ---� �- ----� <br /> ---------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1- 68 Rev. 5M <br />