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FOR OFFICE USE: - <br /> APPLICATION rot-SANITATION PERMIT <br /> (Complete in Triplicate) Permit o. <br /> r <br /> Thi !mit Expires 1 Yepr From Date Issued <br /> ------------- ---- Date Issued __ ______________�/ <br /> Application is hereby made toe an Joaqui 1.4 Health District for a permit to construct and install the work herein <br /> described. This application is ade in compliance with County Ordinance No. 549 and existing Rules` and Regulations: <br /> JOB ADDRESS/LOCATION <br /> Q CENSUS TRACT <br /> Owner's Name -------------------------- ----------- --- r -Phone <br /> ` city <br /> ------ ----------------------------------------•-- <br /> • = 3Address r. <br /> ----- -------------------------- <br /> Contractors Name - ------License # --------�----------- Phone ------------------------- <br /> r <br /> Installation will serve: Residence Apartment House❑ Commercial.[]Trailer Court ;❑ <br /> Motel [-1 Other - ------------ ---------------------------- <br /> Number of living units:----- -__ Number of .bedrooms .-_-__Garbage Grinder W-9- Lot Size _c'►�t_ __7 _________ <br /> Water Supply: Public System and name ---------------------------------------------------------------------------------- ------PrivateK <br /> k <br /> Character of sail to a depth of 3 feet: Sand'[] Silt El Clay F] Peat E] Sandy Loam E] ClayLoom:D <br /> "- Hardpan ❑ Adobe J Fill Material ------------ If yes, type -------________:.'________ <br /> t r 1 i <br /> (Plat 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,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK Size__ __200_ _____________________ Liquid Depth:------------------- <br /> ' Capacity _/ Type -_ -- - Material_ __ No/ Compartments,�----------_---- <br /> ' - <br /> . DistanC� to nearest: Well q6� F dation ___/---------------- <br /> Prop. Line <br /> ---------- <br /> i R �- --- ------------ Length of ach, ne_�_- / <br /> LEACHING LINE •A No.. of Lines � _ g � Q__________________ Total Length. �_��....._.._.__ - <br /> A D' Box __ ` _. Type Filter Material ___ ._ _ pt Filter Material -.IL_�S/ L______________________ <br /> Distance to neaJ\D <br /> { S©____ _ Fou ation � ____ Property' Line. __ ............:.... <br /> SEEPAGE PIT [ ] Depth -------------------- <br /> r _ yNumber _._______________________ Rock Filled Yes No--- --- ---- - - -------- - - <br /> Water Table DeRock Size _ ___._______--- ---- -------•------ ------.__.----Distance to near -- ----------------- --- ------------ p. Line ---------------------±�____Foundat�on Pro REPAIRfADDITION-(Prev. Sanitation Pem _________________________________(Date ____________________....__.--_____Septic Tank (Specify Requirements) ---- -------------------- --------------------- ='------------------------------------=------------------- ------------•------------- <br /> s <br /> DisposalField (Specify Requirements) --------------------------- ----------------------------------------------------------------- - ----------------------•--------------- <br /> x <br /> --------------------- --- -------------------------------------------------- r. <br /> (Draw existing and required addition on reverse side) <br /> ! 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 Districi. 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_shull,�,not,employ any,person in such manner <br /> as to become ublert to Workman's Compensation laws.of California." ; <br /> Signed ----- <br /> BY ----------- --=------------------------------------------------------------- Title ------------------ ------ -- <br /> (If,other.than owner) [ <br /> FOREPART ENT USE ONLY r k <br /> APPLICATION ACCEPTED BY ----------- --------- --- - ------------ ----- -----------iDATE�75 _Z -/;7/----------- <br /> f <br /> BUILDING PERMIT ISSUED -----------------=----------- ------- __.�.--`------------------------- -------- <br /> ADDITIONALCOMMENTS ---------------------------------- ---` `- = f ------------------------ ---------------=--------•-•---------------- <br /> ----------------------------------------------------------------------------------------------------------------------- ---------------------------------=------------------------------------------------ <br /> i3 <br /> ----------------------------------------------------------------------- ----------------- <br /> R lel-2-1 <br /> F -y '. <br /> " <br /> Final Inspection by: i -4 - - " -------------1'Date ---------------- ----------- ----------- <br /> ------------------------------ -------- ----------------=--- �_ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E:H. 9 1-'68 Rev. 5M <br />