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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> -------------------- ------------------------------------ Permit No 1 <br /> _ ; ---------------- -' <br /> (Complete in Triplicate) <br /> ---------------------------------------------------------- <br /> Thls Permit Expires 1 Year From Date Issued Date Issued -------------------- <br /> Application <br /> .----.-6r--YApplication is hereby made to the San Joaquin Local Health District for a per 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/LOCATI N _ -� 1- = -----:fT-,-, ��'— '� --'�_- ----CENSUS TRACT _` 7---------------- <br /> -------------- <br /> Owner's Name - ---------- -------------- --.---Phone ------------- ------------- -------- <br /> wY <br /> Address --- -- �. z _`� �` '.%4 !_� - City r-��[T�- ------------• ------------------------- <br /> Contractor's Name '� ------- ---.License # Phone ---------------------•------- <br /> Installation will serve: Residence EM] Apar ment House❑ Commercial:❑Trailer Court ;❑ <br /> Motel ❑Other _ _-�-__ "�- <br /> Number of living units:.--- ------ Number of bedrooms --_R:_Garbcge Grinder ---- . Lot Size -.- _ '- -a3Y -....... <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 /> Hardpan p� 'Adobe-0 Fill Material ------------ If yes,type ----"----------------------- - <br /> G (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:[ ] Size------------------------------------------------ Liquid Depth --------------------,----- <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 /> c . <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-C] <br /> n <br /> ,.W <br /> Water Table Dept ------------------------------------------------Rock Size -------------------------------- I � <br /> Distancd to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ._-..__._---------. <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ---------___-____-..__-___-__.-___) <br /> i <br /> :. <br /> ptic Tan (Specify Requirements) ----------------- <br /> Disposal <br /> =Disposal Field (Specif Requirements) ---..... - --�-- --- - ---- u '^�'e.. i- ";_ <br /> i ---------- ------------------ - ------------``-— -------`- -Y- ---� �-�--- <br /> a _ <br /> - - ---------------:-- ---------------------------- <br /> lDraw <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 lie done`in-aciordattce 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 -----------------------"-------------- Owner <br /> BY -------------------------------------------- ----- Title _Q.J -------------------------------------- <br /> (if other than owner) <br /> FOR .DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ------------------------------------------ ----------------- DATE -.- --------------- , <br /> BUILDING PERMIT ISSUED ------------------=--------------DATE ----------------------------------------- <br /> ADDITIONAL COMMENTS --------------------------------------------------------- -------_------ = <br /> ------------------------------------------------------------------------------------------------------------------------------------------------- --- ------------------------------------------- - <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ <br /> ------------------ ---- - -- � - <br /> - - - - - ---------- <br /> Final-inspection by - ---- ----------------- <br /> ---------------------- '� --- <br /> -- <br /> Date -------- <br /> ------------------ <br /> SAN JOAQUIN*LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />