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E FOR OFFICE USE: <br /> ,.a .APPLICATION FOR SANITATION PERMIT <br /> ---------- -------- ------ - ��---/�-=------- 1K <br /> (Complete in Triplicate) Permit No. <br /> - • <br />' -- ------ - ------------------------------------------- <br /> -------------------------- 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 Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION _ �✓;/�✓fUr �L�c��--- --- ----------CENSUS TRACT --------------------- ---- <br /> Owner's Name ;r 2 ++ w�'W----------------------------------------------------------------�---------f---Phone <br /> Address /T ----- -1- Cit �Y /IJ-U --- <br /> Contractor's Name .-/Ifs -..G j --------------------------L i ce ns e # _ 53. P h a n e <br /> Installation will serve: Residences Apartment House-E] Commercial:❑Trailer Court '❑ <br /> Motel ❑ Other <br /> Number of living units:_. ___-- Number of bedrooms ___.o-?__,Garbage Grinder �d--- Lot Size _ _ _/00--- ------------ <br /> I <br /> Water Supply: Public System and name ------------------------------------------------------------------------------------- ------------------------Pri\fate ❑ <br /> Character of soil to a depth of 3 feet: Sand'(] Silto Gay ❑ Peat❑ Sandy Loam -❑ Clay Loam,6 <br /> Hardpan ❑ Adobe)e Fill Mciterial ------------ 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,) W <br /> PACKAGE TREATMENT { ] SEPTIC TANK'[ ] Size------------------------------------------------ Liquid ,Depth __ <br /> Capacity ------------------ Type -------------------- Material---------------------- No. Compartments ---------------------- <br /> Distance tb nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ----------------...... ; <br /> LEACHING LINE { ] No. of Lines --- --------------------- Length of each line---------------------------- Total Length ---------------------------- <br /> D' Box ---1-------- Type Filter Material '-----------'°__ ---Depth Filter Material -------------------------------------------- <br /> Distance to nearest: Well ------------------------ Foundation ---_ ------------------- Property Line __-------._-______._____ <br /> SEEPAGE PIT [ ] Depth ----- -------- Diameter ---------------- Number --------- Rock Filled Yes ❑ No f0 <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) --------------------------------------------------------- -- a <br /> - -------------------- ----------------- ---•----- :-------------------- <br /> Disposal Field (Specify Requirements) 1Cf.�8 ' <br /> ..........vre1 �- �------------- <br /> -'; •�3. " ��'�7`------ -------------------------------------------------------------------------------------------------------v------------------------ <br /> 1 <br /> hereby certify that I have prepared th s eappl cation and ired ath______________________________ <br /> dition on reverse side) <br /> e 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 Wor man's'Compensation laws of California." ' <br /> Signed\--- \-'-------------------- -------------- -- - ----------- - --------------- ------------- Owner } <br /> By --------- ---�--- ---- ---- Title t <br /> ----- -- ------ -------------------------- <br /> °�(Ifo than ow er) <br /> F FPARTMENT USE ONLY j <br /> APPLICATION ACCEPTED BY ------ f+ ----------------------------------------•------------------. DATE ----- <br /> BUILDING PERMIT ISSUED -- - -- -- - ------- - ----------------------------------------------------------- ---DATE <br /> ADDI ----------------- <br /> T NAL COMT� '- - ----- ----- - - -- ----------------- -------------------------------------------------------------- -------------------- - <br /> -�� "V A- --- ----------------------- --------- - <br /> ------ <br /> ------------------- --------- -- - -- --- -------- --------------------------------------- ---------------------------------• <br /> Final Inspection by: -----_ _ __ _t � y <br /> ----.Date �� — � / — --- ---- <br /> -JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />