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- R OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> - -- <br /> ---- ---------- , <br /> -- ----- --• -- ----- -- ---- -- (Complete in Triplicate) Permit No. ........... <br /> ------------------------­- <br /> ------- ------- -------- -- - ----- <br /> d�_- ___n_-- 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 Ordinaanc`e No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION .-2-ya_ .1....... ....../�v_S /11/---.-.fGC.........--.......-.....-----CENSUS TRACT _ .._ �__.. <br /> Owner's Name ---.-. L11✓_ .--.Phone -�.%Z <br /> �o f� /U <br /> Address .`. 9 G.. �.h- --- -------------- ----•--. City nX�l��e_f4--- ------------------------------------..---- <br /> Contractor's Name ........ ? 13-/ <br /> . y����/- �-- ------ -------.License # �. ?/- Phone - ---- <br /> Installation will serve: Residence XApartment House❑ Commercial ❑Trailer Court 0 <br /> Motel ❑Other -------------- ---------------------------- <br /> Number of living units:.....C....._ Number of bedrooms _..._.Garbage Grinder -ND--- Lot Size <br /> Water Supply: Public System and name ---------------------•------------------- ---------------------------------------------- Private <br /> Character of soil to a depth of 3 feet: Sand Silt❑ Clay ❑ Peat E] Sandy Loam Clay Loam ❑ <br /> Hardpan ❑ Adobe ❑ Fill Material _Nff._ 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 /> PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] Siz ----------------------------------------------- Liquid Depth --- ---------------------- IN <br /> Capacity -------------------- Type ---------------- -- Material--_.---------------- No. Compartments ...................... <br /> Distance to nearest: Well --- ------------- --_-------------Foundation -_--_--_--.__--___-. Prop. Line ---.____--_-_--___-. � <br /> LEACHING LINE [ ] No. of Lines _ -- _----------- -_ Length o each line.-_.................. Total Length -.--.--_--------_-_-_-____ <br /> 'D' Box ------------ Type Filter Material ----------------•Depth Filter Material ............................................ <br /> Distance to nearest: Well -------------------- --- Foundation -.-.---------..--.-..... Property Line ........................ <br /> SEEPAGE PIT [ j Depth -._---_.-_---_-. Diameter ----------- ._. Number ---------------------------- Rock Filled Yes ❑ No i❑ ' <br /> Water Table Depth -------_------------------- -----------_-----Rock Size ---------------------------•--- <br /> Distance to nearest: Well .................. Foundation ..--..---------.---. Prop. Line .-.................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ---..._-..-:`--------------- -------------- Date ---------------------------------- <br /> SepticTank (Specify Requirements) ---------------•--- ---------------------'------- ------------------------------•--------- --------•---------•-'-----------_-_-------- <br /> Disposal Field (Specify Requirements) � �__._...'/ ,�u e.. d---- 0.---. <br /> /c-------��--------�'-moi� � S'y •1� - <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: <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 ------- -- --------------------------a-- ------- Owner <br /> ---- -------- -- <br /> BY -. - -' Title . <br /> --------- -- --------- -- - --- ---- <br /> (If other than owner) <br /> j� FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY .. t I ----------•---------------------------'_------------------•---•-•-•-----. DATE ----- -5-7,70---------- <br /> BUILDINGPERMIT ISSUED -------- --•--------------------------- -----•-----------•------•-----•-•------------------•--------•- ---DATE - ---------------------------------- <br /> ADDITIONAL <br /> ------------•-----------•------ <br /> ADDITIONAL COMMENTS -'-- ............................. - <br /> ------------ <br /> -------Date 'J =---------------- ---- ------ ----- ---­---------------- ------ ---•--• ---------------------------------------------------�--------•A--•'1- <br /> ................ --- --- - - - ------ -- ------ ------------------------------------------------ <br /> Final <br /> ------------------------.----- -------------- <br /> Final InsP <br /> . . <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />