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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> �-IF-------9���-�.xc� Permit No, ---- -- ----/�-� <br /> (Complete in Triplicate) <br /> ---------------------------------------- ----------- ---- <br /> This Permit Expires 1 Year From Date Issued 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 with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOC TION -__ -,_ ---------CENSUS TRACT .__--.---_--.-.--_---_-_-- <br /> 7 ✓ <br /> Owner' Nam - <br /> --------.Phone � <br /> Address � --------------------------------------------------------------- <br /> a <br /> _ Cit <br /> S 7 S Phoned7`�Contractor's NameE - = - 7 ---- --- - - <br /> Installation will serve: Residence ['Apartment House❑ Commercial[]Trailer Court ;(] <br /> ) I Motel E]Other-------------------------------------------- <br /> Number of living units--------l.-- Number of bedr�ororpss _-4-_-Garbage Grinder _'1*4 ..-- Lot Size ZU-------------------------------------- <br /> Water Supply: Public System and name ------------- ✓`if -----------------------------------------------------------------------------Private El <br /> Character of soil to a depth of 3 feet: Sand'E] 511t❑ Clay ❑ Peat❑ Sandy Loam -❑ . Clay Loam :0 <br /> Hardpan ❑ Adobe R�Fill Material ----- ------ If yes, type _____________________-_____ <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 /> r <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ) j %. w. Size-----------------------------------•----- ------ Liquid Depth ------------------.------- oQ <br /> Capacity.- --------- ------ Type --------------5---- Material---------------------- No. Compartments --------------- <br /> t <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 --------------------.--__-_-.--_-_-_.-__-_-_ <br /> ( ------ Property Line -------------- •-- <br /> Distance to nearest: Wel! ________________________ Foundation __-_-.-:---._ _ _ <br /> SEEPAGE PIT [ J Depth --__t-_-_----_-_--- Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No :0 <br /> Water Table Depth-----------------------------'---------- --------Rock Size -------------------------------- <br /> Distance to nearest: Well -------------------- ------------------Foundation ---------------.---- Prop. Line _--------_--_ ........ <br /> REPAIR/ADDITION(Prev. SanitationPermit}# ----------------_----.--.----_-__---_---- -_Date --_-_---_-__----__.--____-_-_-_-) <br /> i I * � 1 <br /> Septic Tank (Specify Recluirementsl -------- ------------------------------ ------ -- ------`-----------1 --------------------------- <br /> Disposal Field (Specify Requirements) r <br /> '------------------------------------------------------------------ <br /> -------------------------------------------------------------:-------------------- -------------------------_------------- ------------------------------------------------------------------- <br /> I (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: <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 become b' ct to Workman's Compensation laws of California." <br /> J k <br /> r <br /> -� -_---___ Owner <br /> ` S <br /> Signed ---�------- <br /> BY ----- Z------------------�---------- ----------- -------------- <br /> ------------- . Title <br /> --------------------------- <br /> (If other than`owner}: ,Y. <br /> FOR .DEPARTMENT USE ONLY # <br /> APPLICATION ACCEPTED BY ------- ---- ------- -� -------------- <br /> -------------- DATE 4f ,(� <br /> BUILDING PERMIT ISSUED ----------------------------------------------- t------------DATE --------------------------- <br /> -- - --------------- <br /> ADDITIONAL COMMENTS --------- -------------- --------------------------------------=--------------------------- <br /> ---------------------------------------------------------a -�� e-' ----------- - -- <br /> - <br /> ---- <br /> - - - - - ------- - <br /> D> <br /> ----------- <br /> Final Inspection by.. '_-._ — ---.Date <br /> ,SAN.JOAQUIN LOCAL.HEALTH, DISTRICT# <br /> E. H. 9 1-'68 Rev. 5M - i Y <br />