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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> -- --- -------- ------ - Permit No. ------�-------------� <br /> (Complete in Triplicate) <br /> ------------------ ------------- <br /> -------------------- This Permit Expires 1 Year From Date Issued Date Issued <br /> - <br /> Appli ation 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 DDRESS�LOCATION -----CENSUS TRACT ----------------_------- <br /> S <br /> s Sa NaRA �6-SS3� <br /> Owner's Name _ -----------------------------------------------------------Phone - ------------------------•-- ----- <br /> Addrss -- ----------------------- --------------------------------------------------------------------------- Cit ------ <br /> - /��,QUc <br /> Contractor's Name _. %_11JZc� 0,�,9i___�/9�C`c� l Ca.v ---_--. cense #0_4------- - Phone ------------------------------ <br /> Instal ation will serve: Residence❑ Apartment House❑ Commercial ❑Trailer Court <br /> Motel.NL _/VVM�----------�1------- <br /> Number of living units_____________ Number of bedrooms ------------Garbage Grinder - Lot Size .20�¢ s'--..---- <br /> Wate Supply: Public System and name --------------- --'------------------------------------------------------•------------------------------------Private <br /> 6` <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay Peat❑ Sandy Loam -❑ Clay Loam E] <br /> Hardpan ❑ Adobe ❑ Fill Material ------------ If yes, type ______________________ <br /> (Plot ;Ian, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW NSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACK kGE TREATMENT X SEPTIC TANK [ ] Size--- ____________________ Liquid Depth ______----___________--___ <br /> Capacity aU_._____ Type __ Material____- �7/do. Compartments __._._____ <br /> ----_--- <br /> // ! �- <br /> Distance to nearest: Well --/00 ____________Foundation ---1-_�_ -------- Prop. Line _`___�_`_____,__�_/__._.._.__ <br /> LEAC 1NG LINE [ ] No. of Eines ______ ____________ Length of each lin ____ d Total Length <br /> D' Box ____�_-_ Type Filter Material ' ------ epth Filter Material -___----_ ___.____________________ <br /> (11, Distance to'nearest: Well _____________I_�[___,-,_G__r_ Foundation ------------------------ Property Line. ________________......-- <br /> SE G&PIT [ ] Depth -_1O-_---------- Diameter _�_ O__--. Number ----------\---------------- Rock Filled Yes 0 No <br /> la Water Table Depth ---=---------------------------------------•----Rock Size ---------------------------- <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ----------.._...__..__ <br /> REPAI tfADDITION(Prev. Sanitation Permit# -------- ----------------------------------- Date _____________________________----J <br /> Se .is Tank (Specify Requirements) ---------------------------------------------------------------------------------------------------------------------------------------•-••- <br /> Disosal Field (Specify Requirements) ----------_-------------------------------------------------------------------------------------------------------------------------- <br /> ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> -------------------------- -------------- - - -------------------------------------------------------------------------------------------------------------------------------------- <br /> (Draw existing and required addition on reverse side) <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> Count'r 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 cert fy 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 1,19,coTe subject to Workman's Compensation laws of California." <br /> / <br /> �5igned -- Owner <br /> By ----- ------------------------------------------------------------------ ----- Title <br /> (If other than owner) <br /> FOR DEPARTMENT USE. ONLY <br /> APPLH ATION ACCEPTED BY -��f-------------------------- �-.-- - ------.----------------- DATE ---9 ---!;_77 ---------------- <br /> BUILDNG PERMIT ISSUED ------------------------------------------ -------------------- -----------------------------------DATE ------------------------------------------ <br /> ADDI1ONAL COMMENTS ----------------------------------------------------------------------------------------------------------------------------------=--------------------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ---------------------------------- ----- - -- ----- <br /> ----------------------------------------------------------- ------------------ --- ---------- - - -- <br /> Final Inspection by: Date --- - <br /> _ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />