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FOR OFFICE USE: <br /> -APPLICATION FOR SANITATION PERMIT <br /> {Complete in Triplicate} Permit No. - _ 1 <br /> f _______________________ This Perrnit'Expires I�Y4 From b t 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 Coun y Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION -- � - -- -------------------------------CENSUS TRACT ,7----_-_---l--l-.- ----------- <br /> Owner's <br /> ---- <br /> Name ----------------- / -- - -- - ------__- ---------------------------------- Phone <br /> Address <br /> ---- --------------------- _- '" �" -° City <br /> Contractor's Name --____---_ ---------------------------------------------License # ____ Phone <br /> Installation will serve: Residence Apartment House-E] Commercial :❑Trailer Court ',❑ 7a <br /> Motel ❑Other -------------------------------------------- <br /> Number <br /> -------------------------------------------Number of living units ----- Number of bedrooms ----<__ _Garbage G ' der __.____ _ Lot ize ______16 _ ----- ___________________ <br /> Water Supply: Public System and name ----------------------------------t`-----------:--------------- -----.-----Private E]Character of soil to a depth of 3 feet: Sand'[] silt 0 Clay' t <br /> E] EMIPeat andy Loam -❑ Clay Loam ❑ <br /> . 1 <br /> Hardpan E] Adobe Fill Material __________ If yes, type ________________________ ___ <br /> (Plot plan, showing size of lot, location of system yin relation to wells,-build ings,#etc. must be placed on reverse side.) <br /> 1 Q <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted,if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK[ ] i �Siie_ __ _ '- - ------------------------------ Liqu1d'Depth ----------- _--------- <br /> I .I <br /> Capacity --------------------- Type -------------------- Material---------------------- No. Compartments ------------.._..:... <br /> Distance to nearest: Well _____ ; t �,y� <br /> Foundation i Prop. Line <br /> ------- -------•------ <br /> . i <br /> LEACHING LINE [ ] No. of Limes ________________________ Length of each .line--------------_------------- Total Length _ <br /> D' Box ............ Type Filter Materia! _____________ ______Depth Filter Material ----.-- _.__;___'" __________-___-------- <br /> Distance to nearest: Well _______________________ Foundation _____----_-y_______----"dProperty 'Line --__:__`--:__~___-----_-_ <br /> SEEPAGE PIT [ ] Depth %Diameter ---------------- Number ---------------------------- Rock'Filled Yes El No ❑ <br /> ` :Water Table-Depth,, '-------`-- -^ _ Rock Sizer.-ate-----------------:--- <br /> Distance to nearest Well ---- ----------------------------------Foundation -------------------- Prop. Line -----------. --_..--• <br /> REPAIR/ADDITION(Prev, Sanitation Permit# ___________ -------------------------------- Date ----------------------------------) <br /> Septic Tank (Specify Requirements) ----------- ---------------------------- f - <br /> Disposal Field (Specify Requirements) --------- ---=-- -- <br /> -- --L_._G <br /> -------------------------------------------------------------- --- X----------------- ----------- --- ------- = ---------------- <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 Sane 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 subject to Workman's Compensation laws of California." <br /> Signed --------------------- -------------------. Owner w <br /> BYaTitle ---------------------------------------------------------- <br /> (If <br /> - ---- ----------------------------------------- <br /> (If other than o r) <br /> FOR DEPARTMENT USE ONLY <br /> ------------------- <br /> APPLICATION ACCEPTED BY - 9----- ----------------------------------------------- ----- DATE r.� <br /> BUILDING PERMIT ISSUED ---- -- - _-- ------------------------DATE .......----------------------- <br /> ADDITIONALCOMMENTS -------------------------------------------------------------------------------------------------------------------------------- ------------ - ------- <br /> --- 1 _ = ------ -- --------------- - --------------- ---- --------------------------------------- - _--------- <br /> -------------- <br /> ----------------------------------- ------ - ------------------------------------------------------------------------------------------- ---- <br /> ---- N---- r$ <br /> FinalInspection by: - - -------------------------------------------------------------------------------- Date -- ------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />