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APPLICATION FOR SANI`ATION PE€'RUT <br /> . .-_....--•-- •--•--- ------ -- - -•--------•• Permit No. -`o—//( <br /> (Camrpleta in Triplicate) <br /> --------------------------- This PermitExpire_s ? Year rorn Data 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 com�-plliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION '�'�!__�5�.'_-. ----_--------------CENSUS TRACT ......�b-_--------- <br /> Owner's Name ✓ ------­-------- <br /> ��-�t-��.4: �,.•-• �'�.��•--�-•----•---_. -- '.f�.'.!��.v:�.-----•=---------------- •- Phone <br /> Address /.ate-�,� ;��' L tY.3�� a <br /> ......................................... <br /> Contractor's Name '' <br /> -- F-�.,_�_.�_:.-f--�-1r==--�----=�---=-�--=---°-----------=--'L---'•------�-------.License # �--.. :.-----�--------- Phone ---J- •-r-:__....---•---__-_ <br /> Installation will serve: Residence E]Apartment House❑ Commercial ❑Trailer Court ❑ <br /> Motel ❑ Other -------------------------------------------- <br /> Number <br /> ---------------------- - ------------------ <br /> Number of living units_____________ Number of bedrooms ___:::'.._.Garbage Grinder ............ Lot Size ------------- _-__ <br /> Supply: Public System and name ----- ----------------•-------------•-•--•-•---•-----• -------•••-..... -------------------------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam }{-'J Clay Loam ❑ <br /> Hardpan ❑ Adobe ❑ Fill Material ............ If yes,type ---------------------------- <br /> (Plot plan, showing size of iotr 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 I ] Size................................................ Liquid Depth --------------.......... <br /> -. <br /> Capacity --------- -------- 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 __...................................-_-_-- <br /> Distance to nearest: Well ------------------ Foundation ----------------------- Property Line <br /> SEEPAGE PIT [ ] Depth . Diameter ________________ Number Rock Filled Yes €,] No ❑ <br /> Water Table Depth ................................. ........-...-.Rock Size ......... ---------------------- <br /> Distance to nearest: Well ........_...............__._.___.___---Foundation __......._.._-_.... Prop. Une .---.. ..... -"--.... <br /> REPAIR/ADDITION(Prev. Sanitation Permit Date ......._...._--•--------------- - <br /> Septic Tank (Specify Requirements ..... --------------*------- .... - <br /> Disposal Field {Specify Requirements) <br /> ._ .. ----r•••..............•-•••-•----- <br /> ti <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 Sada Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Rome owner or licen <br /> sed agents signature certifies the following: <br /> "I certify that in the perrormance of the work for which this permit is issued, I shall not employ csny person in such rnanne: <br /> 6s to become subject to Workman's Compensation laws of California.,, <br /> Signed .. ------------------------------------ :----- - Owner <br /> B5' Title ....... •- - - <br /> (1r otherr than owner) <br /> -FOR DEPARTMENT USE ONLY <br /> DATE ------------�--------------- <br /> APPLICATION ACCEPTED BY - --•--• --------------------- ------ ----•------------------- -----•----••-----•--------- 6 <br /> BUILDING PERMIT ISSUED ------------- ------------------------------------DATE ---•--------- ---------• -•--•-- .......... <br /> ADDITIONALCOMMENTS - -----•-•---------•-•------•----------•--------•------------------------------------------------------------------------- ----•--•-•------------------•---••- <br /> - --------------------------------------------- -- ----•-----------------•----- -- -----------------------•---••-----------•-----------------•----•-••------•----------------------- ----- - ­­-- <br /> ------------------------------- ----- <br /> Final Inspection by: Feil ----------------- -----------------------------------------------------Date% ...'.. ..._ ----------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 '-'68 Rev. 5M <br />