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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> +� Permit No. <br /> (Complete in Triplicate) <br /> ---- ---------------------------------------------- <br /> Date Issued _lam`.-- -jam <br /> _--_---_, -- This Permit Expires 1 Year From 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 r liaa with County Ordinance No. 549 and existing Rules and Regulations: <br /> 4 /�ll , I S c� -------- -- - -----CENSUS TRACT -------- --_-- <br /> JOB ADDRESS/LOCATION __._..--5__�_1_____ -,- ---t--� G <br /> U1 - L� <br /> Sd L4+" V elV 7KN ------------------------------Phone.- -Z- - - 1�-•-- <br /> Owner's Name --- <br /> ------ G r— <br /> !_- ---. Citp <br /> Address17i _ Y ; - t <br /> Contractor's Name ------- ------------------------- `.License # ----`1_7 ------- Phone ------------------------------- <br /> Installation <br /> ------------- --------•-•---Installation will sere: Residence1<Apartment House°0 Commercial ❑Trailer Court 'El <br /> ! Motel ❑ Other ------------------ ------------------------- <br /> Number of.living units:____I_-.__ Number of bedrooms ,-A------Garbage Grinder ----- ------ Lot Size ____________________________________________ <br />` Water Supply: Public System and name ------------------------------------------------------- ---------•-------•------------------------------------Private ❑ <br /> Character of soil toga depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑. Sandy Loam ❑ Clay Loam <br /> Hardpan ❑ Adobe ❑ Fill Material ----- ------ 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 pulZic-sewer is available within 200 feet,) <br /> I' _ SEPTIC TANK _ F <br /> Size__ <br /> Li uid Depth __/________ \\oPACKAGE TREATMENT ------------------ <br /> --Material----- <br /> - �✓ <br /> Material No. Compartments <br /> Capacity --------------t- Type -------------------_ p. line -------Distance to nearest: Well ------------ ---------- ---------- Foundation ---------------------- Pro <br /> � <br /> �.D <br /> Len th of each line_____ e Total Length _1 - --.--- `C <br /> LEACHING LINE [ ] No. of Lines --------- --- - J----- , r> i <br /> 'D' Box ._'_ -. _.- Type Filter Material _-----------------Depth I filter Material�_._.----- _-_-. _ <br /> — Distance to nearest: Well __._ � Foundation _____.___--`_--_._____- Property Line <br /> --. - <br /> SEEPAGE PIT Depth _ Diameter -------- NumhRock Size <br /> er. ,_________-------------_- Rock Filled Yes"[3 No i❑ <br /> --------------- ---- <br /> Water Fable Depth _ <br /> S Distance to nearest: Well --------------------------------------- Foundation -------------------- Prop. Line _------------- ------ <br /> I <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date -----------------------•----------} <br /> Septic Tank (Specify Requirements) ---------------------------------------------------------------------------------•--------------------- ----------f-------- :r----•-------- <br /> Disposal .Field (Specify Requirements) ----------- ----, ----------- <br /> ---------------- <br /> ---------- --- --------- ----- - - J <br /> ----------------------------------------------------------------------------------- <br /> -------------------------- ' 3 � i� n.,. <br /> ----------- <br /> - -- >> --------- <br /> - <br /> (Draw existing and required ad =tion on reverse fide) <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 shalt not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed ---------------------------- -------------------------------------------------------------------- Owner <br /> ------------ Title ------=---------------------------- ------------------------------------ <br /> (If other than owner) <br /> I FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY _._ -- -- DATE -- ---~— ---------------- <br /> BUILDING PERMIT ISSUED --------------------- DATE ------------------------------------------ <br /> ------------------------- <br /> ADDITIONALCOMMENTS ------- -------------------- ------------------------------------------------ -------------=---------------•----------- <br /> ---------- -------------------------- ---------- ----------------------------------------------------------------------------------------------------------------------------- <br /> ------------------------------------------------ - - <br /> i <br /> - - -- -- ------ ------- ---- ----------------------------------------------------------------------------- <br /> Final Inspection by: -------- ------ ---- -- ------ ---A-----------------------------------------Date --- --- <br /> SAN"JO QUIN LOCAL HEALTH DISTRICT ���I <br /> AP )t 5 A ze- 1._)-b � � ' <br /> E. H.'9 \l-'68 Rev. 5M <br />