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i <br /> FOR OFFICE USE: <br /> ----- --------------- - <br /> APPLICATION FOR SANITATION PERMIT <br /> Permit No: ..------- - <br /> (Complete in Triplicate) --- <br /> ---------=---------------------------------------------- <br /> ------ ------------------------------- ---------- <br /> This Permit Expires 1 Year From Date Issued Date issued <br /> - -- .✓'.:� �__ <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 <br /> JOB ADDRESS/LOCATION - ----'� - '-'S---- ------_ --L --- ---------------------------CENSUS TRACT - "71__.----------- ' <br /> Owner's Name ----- - ----------------- -_----------- ---`--'---Phone ------------------------------------ <br /> - <br /> Address - ------- ---- - S'?-.3� Cit -r 's� <br /> Y ---= <br /> Contractor's Name --_- _- 4 ' -__- ---•--_ i.�-- _License # __ � .s' y Phone ------------------------------ <br /> 1�!�-cr - <br /> Installation will serve: Residence [Apartment House[] Commercial :❑Trailer Court ;❑ <br /> Motel ❑Other ------------------------------------------- <br /> Number of living units:------ Number of bedrooms ________Garbage Grinder �!`1� Lot Size _��-may''-_______________ <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 /> h Hardpan ❑ Adobe-❑ Fill Material _.__ ------- If yes,type ______.__._____________-__ <br /> (PI'ot 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 TREA <br /> TMENT [ ] SEPTIC TANK'[,] / Sizei q p <br /> ------------------------------------------- ---- Liquid Depth ---------------------.----- <br /> # Capacity -------- --- -. Type ' ---------------- <br /> Material------------------.---- No. Compartments --------- •••------ �+ <br /> Distance to nearest: Well ----------------------------------Foundation ---------------------- Prop. Line ------------_--_--- <br /> LEACHING <br /> -----------_--._ ---LEACHING LINE ( ] No. of Lines :-------_-Length of each line----------.----------------- Total Length <br /> ----------- <br /> D' Box ___________ Type Filter Material ____________________Depth Filter Material -----------------.__________._..____.____ <br /> Distance to nearest; Well ------------- <br /> ----- Foundation ________________________ Property Line __________--_.__-:--__ <br /> SEEPAGE PIT [ ] Depth '- '__' {Diameter ---_ _- --_-_ Number ---------------------------- Rock Filled Yes ❑ No <br /> { <br /> z,w Water Table Depth.---------------------------------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well --------------- -----------------------Foundation -------------------- Prop. Line --------------..------ <br /> REPAIR/ADDITION(Prev. Sanitation Permit#-----_-___'{___-----------_________________ Date ________---_,_______--_______-_--) <br /> Septic Tank (Specify Requirements) - - . ' ----------------------------------------- ---- ------------------- <br /> i--~-----f--'---- --- <br /> Disposal Field (Specify Requ'remen ] _ _ __ _Y- - -r-i __ ________ _ ______ �..�__________ <br /> I o-- 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, State Laws, and Rules and Regulations of the San Joaquin'local Health District. Home owner or licen- <br /> sed agents signature certifies the following: y <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 beta a subject to Workman's Compensation laws of California." <br /> 'SignedOwner <br /> - Title <br /> - �BY --------- . - ------------- <br /> (If <br /> other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED B DATE -------------------- <br /> BUILDING' PERMIT ISSUED - --- -- --------=-.: .. --• -__BATE -_--_.--_- <br /> ADDITIONALCOMMENTS -----------------•--------------------------------------------------------------------------------------------------------------- ---------------- ---------- <br /> ------------------------------------- ----------- ------------------------------------------------------------------------------------------------------------------------------- <br /> ------------------------------------------- --------- --- <br /> ------------ --------------- - -- =------- <br /> Final Inspection by: . _ ------- ------- - -- -------- -- ----•------------------ -------------.Date --- - ----------- <br /> 'SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M. <br /> I <br />