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FOR OFFICE-USE: APPLICATION FOR SANITATION PERMIT <br /> " b a Permit No. o+----------------------------- <br /> (Complete in Triplicate) , <br /> --- ------------------ ----------------------- --- p <br /> - Date Issued ����-.. <br /> This Permit Expires 1 Year From Date Issued <br /> --------------- <br /> Application is hereby made'to the San Joaquin Local Health District for a permit to construct and instal) the work herein <br /> described. This application is made in compliance with County Ordinance No. 5.49 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION .-I <br /> rl- 7 - _ �------- CENSUS TRACT <br /> Phone <br /> Owner's Name �> L ' <br /> Address --------------------- '''�E ------=---------------------------------------------,... CifiY � f <br /> Contractor's Name __-- .. .-r-l_iaa...... :c . ------- -- ---- <br /> License # �����7 --- Phone - _ � • <br /> = ''� .— <br /> Installation will serve: ResidenceApartment House❑ Commercial :❑Trailer Court 'F_1Motel ❑Other ------------------------------------------- <br /> Number of living units;----- Number of bedrooms --�------Garbage Grinder --YV- a-. Lot Size _--_ -----------_1�C-.°--------- <br /> Water Supply: Public System and name ........ ' --------------- -•---------Private El��TL.L.- f <br /> — <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 ---------------------------- j <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,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK'[ Size-----------------------------------------------; Liquid Depth --- ----------- <br /> CaN acit - Type -------------------- Material---------------------- No. Compartments :-----•---------.:---= <br /> Distance to nearest: Well ------------------------------------Foundation ----___-____---______ Prop. Line ______________________ <br /> LEACHING LINE No'. of Lines " ---------------------- Length of each line-------------.____----.______ Total Length ----------------------- <br /> [ ] D Box ------------ Type Filter Material --------------------Depth Filter Material --------------------•--------------------- - YA <br /> Distance to nearest: Well _-----`---------------- Foundation ------------------------ Property Line ____-___.-.-_-----.----- <br /> SEEPAGE P1T \]�� Depth JAS~'___ Diameter :33------- Number -------_ "------_---- Rock Filled Yes No �J <br /> f 3 N <br /> Water Table Depth ---- ------------------- Rock Size ----- -------- <br /> ---------- --- - <br /> Distance to nearest: Well ----- -------------------Foundation-_-_--/d- ------ Prop. Line ......6.._ ... <br /> _.___.. <br /> i REPAIR/ADDITION(Prev. Sanitation Permit# -----•-------------------------------------- Date ---------'------------------------- <br /> Septic <br /> --=-----------Se tic Tank (Specify Re ;uirements) ------------------ -------------------- -----------------------------------------------------------------------,•_--------------------------- <br /> Disposal Field (Specify Requirements) _- �1 � �------•- � <br /> 4X/ // ✓ ------2; 7101 ------------------------------------ <br /> r <br /> -------- =--------------------------------------- <br /> ----------------------------- <br /> ---- ---- ----------------------------- ---------- ------------------------- ------------------------------------------------------- <br /> ------------------------------ <br /> r F (Draw existing and required,addition on reverse side) <br /> I hereby certify that I have prepared this applicatiori­and Nat 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 beco uble o Workman's Compensation laws of California." <br /> Signed __ ------- - ---------------------------- Owner _ <br /> Title ---------------------- -- ---------------------------------------------- <br /> BY - ----- -------- --- lam c' 'J <br /> (If other than owner) <br /> F R DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED 'BY ----- -- ----------------------- DATE ----- -- ----------- --��------- <br /> BUILDING PERMIT ISSUED --------- ---- ------------------------DATE ------------------------------------------- <br /> ADDITIONAL COMMENTS'-------------------------------------- -- ------------------------------------- <br /> - <br /> ----- ----------------- <br /> - -------------- <br /> i ---------------------------------- <br /> --------------------------------------------------------------------------------------------------------------------------- <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> -------------------- ---- -- ------------ --------------------------------------------------------------------------------- --------- <br /> Final Inspection by: ______ <br /> --------------------------- --------.Date <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'6B Rev. 5M <br />