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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit No.7Q- <br /> ------=-- - - -- - <br /> t �` '� <br /> --------------- This Permit Expires 1 Year From Date Issued Date Issuedla--�6 - .4 <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 Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATI ------- --p A_ --c-' C ------_----- -- <br /> ------------------------------CENSUS TRACT --------------- ---------- <br /> .-f <br /> Owner's Name -- - -------------- ---------- <br /> - <br /> - - - --------------- Phone------------------------------------ <br /> Address ---,-- ------!/ � City ' .------- "s--------------------------------•--- -•---•--- <br /> �- <br /> Contractor's Name -- __--- _-- -i----- ---- ,�-___--.License,# _,tt t3e;;'Phone _______________________•.----- <br /> Installation will serve: Residence ❑Apartment House❑ Commercial ❑Trailer Court ;❑ <br /> Motel ❑Other ------.-------------------------------------- E <br /> Number of living units:----IV----- Number of bedrooms.- ----_Garbage Grinder ------------ Lot Size -------------------------------------------- <br /> Water Supply: Public System and name -------------------------- ----------=---•--------------------------------•-------------------- --------------Private [� <br /> Character of sail to a depth of 3 feet:- Sand'❑ Silt E] -Clay,E]: Peat[iµ Sandy ' Clay Loam ❑ <br /> Hardpan ❑ Adobe ❑ Fill Material ____________ If yes,type ---------------------------- <br /> (Plot <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'[ ] 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 /> 'D' <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 /> Water Table Depth --.--..Rock Size -------------.---------_ <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line -------..--........... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------- ----------------------------------- Date ----------------------------------) <br /> Septic Tank (Specify Requirements) ----------------------------------------------- <br /> Disposal Field (Specify Requirements) -_ -, --- --- - - 4 _ �c.�ar_ � �______-_____ <br /> z's--l------------ - <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 ---------------- -------------------------- ------------- Owner <br /> B <br /> Y ---........ --- - <br /> = Title ly------------------------------------------- <br /> (If other than owner) <br /> „FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ---------------------------------------------------------------. DATE -/d � 0--------------- <br /> BUILDINGPERMIT ISSUED ----------------------------------------------------------------------------------------------------------DATE ------------- ------------ ---------------- <br /> ADDITIONAL COMMENTS = <br /> --------------------- ----------------------------------------------------------------------------------------------------------------------------•--------------------------- <br /> ------- <br /> ----------------------------------------------------------- ----- --------- --- ------------ - <br /> Final Inspection by: -- --- ------------------•---------------------------------------------------Date J -l•3'-*70-- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />