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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> -------------------- ---- --------- Permit No. - <br /> ---------------- r (Complete in Triplicate) _ <br /> ----------I----------------------------------------------- <br /> Date issued /__l .__ <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 ith-County Ordinance 549 and existing 'Rules and Regulations: <br /> JOB ADDRESS/LOCATION .-- --- ------- I-d_ -- CENSUS TRACT <br /> ��'� = 1 r� <br /> Owner's Name -.---- ------------------ ---------------------Phoneda---/--7S <br /> - - ----------------------------------------- <br /> Address ------------------- -- - -- - - - --- city --- - <br /> Contractor's Name ------------ ---- ' -- ---==--*---.License# ------------------------ Phone <br /> ` _- <br /> Installation will serve: Residence ❑ Apartment House-E] Commercial❑Trailer Court <br /> Motel 0 Other -------------- ----- = <br /> �J 1 <br /> Number of living anits:_ __l--.- Number of bedrooms __s�-___Garbage Grinder,-Y-----_-__ Lot Size'-,wr__ _�-- - ------------------------- <br /> Water Supply: Public System and name ----------------------------____-__---__ ------ � "� { Private <br /> t:�-----4-------- y <br /> Character of soil to a deep of,3 feet: -Sand'❑ (Silt❑ Clay-[�---Peat❑- Sand '.Loom.-❑ CI-6y-LoLoom <br /> t - Adobe -Fill Materia`I"""--- "'ffyes,type ---------------------------- <br /> Hardpan-E] <br /> (Piot plan, showing size of lot, location of system in relation towells, buildings, etc, must be placed on reverse side.) <br /> NEW INSTALLATION:3 (No septic tankforiseepage pit permitted if, public sewer is available within 200 feet,j �y <br /> 4,/ • r' , <br /> PACKAGE TREATMENT [ ) SEPTIC TANK [ Size___--`----------------------------------------- Liquid Depth --------------------------- <br /> Capacity _-__iT a -------------------- Material----_---___________-r+tNo: Compartments ---_-_.--_-:._.._._.._ <br /> p Y ------ ---- - Type � \ <br /> ! Distance to nearest: Well ------------------------ -----------Foundation ------�``-� '.Prop. Line -------.--------..---- <br /> LEACHING LINE [ if No. of Lines ------------------------ Length of each line----______y--.-------_---- Total Length ---------------------------- <br /> 'D' <br /> _-_--- __.-____-____--'D' Box ------------ Type Filter Material---------------------Depth Filter Material ------------------------------.------.------ <br /> Distance to nearest: Well -----I-_---k___.J- Foundation ------------------------ Property Line. __-_--_.--_...--------- <br /> SEEPAGE PIT [ ] Depth { ---- Diameter ____-_--_-- Number ---------------------------- Rock Filled Yes 'EJ No 0 <br /> * Water Tablev Depth -------------- ---------------- Rock Size <br /> ---------------- <br /> Distance to nearest: Well ---------------------------------------.Foundation -------------------- Prop. Line -.-.------------------ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# --------------------------------------- ---- Date ---------------------------------- <br /> F f <br /> Septic Tank (Specify Requirements)-------- --- ------=--=--------- -------------- ---- --, ------- - ---- ------ ---------- <br /> -- <br /> - ------------ <br /> f <br /> Disposal Field (Specify Requirements) ------------------ --- -_------ t� <br /> ------------------------------------------------------------ ---------------------- .�. z�S _x ---- -- ---- ------------------------ <br /> I I i <br /> -------------------- ------- --------------------------------------------------------------- :------------------------------------------------------------------------------------------------------ <br /> ! (Draw existing and required addition on reverse side) <br /> I hereby certify that 1 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: I �� <br /> "I ce'rtify`fh'at 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 ------i------- -------------- -------- <br /> ------ ------------- ------ Owner <br /> BYI <br /> other n owner) <br /> t FOR DEPARTMENT USE ONLY <br /> APPLICATION' ACCEPTED BY ----------------------------- �_- __. DATE. �� J �'. <br /> ------------------------ <br /> BUILDINGPERMIT ISSUED -------------------- ------------------------------------- F---------------------------------------------DATE ------------------------------------------- <br /> ADDITIONALCOMMENTS '=--------------------- = ----'------------------------------------------------------------------------- <br /> i------ - �. — --- .a----- <br /> ---------------------------------------------------------------------------------------------------- <br /> - <br /> *kv - <br /> -----------------Date <br /> Final Inspection by: ------------------ -- �' <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />