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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ---------------------- ----------------------- <br /> (Complete in Triplicate) Permit No. _- "-Z. _.. <br /> ------ <br /> 1 Date Issued --- <br /> ------------------------------------------- -------------- This Permit Expires I Year From Date Issued <br /> A�:Zcation 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 N -------- -------------- -----------�-�----���----------A,------ - -- --- - ENSUS TRACT __.----_�----------- - - <br /> Owner's Name �1 ---- -- - ---- ------- --_ <br /> Phone --------------------------- <br /> Address i!5-_ ej---------- -------�-. Ci 7��- -------------------------------- ----•--- <br /> tY <br /> Contractor's Name ----------------------- ----- License #3_`�l-7_ _ __ Phone <br /> Installation will serve: Residence partment House,0 Commercial ❑Trailer'Court ;❑ <br /> Motel ❑ Other -------------------------------------------- <br /> Number of, living units--------�.___ Number of bedrooms ______Garbage Grinder Lys_ Lot Size -�-�----------------------------------- <br /> Water Supply: Public System and name --------------------------------•-------------- :-----------------------------=---------------I-----------------Private <br /> Character of soil to a depth of 3 feet: Sand;% Silt❑ Clay E] Peat E] Sandy Loam -E] Clay Loam "❑ <br /> Hardpan ❑ Adobe,E] Fill Material ------------ If yes,type ---------------------------- <br /> 41 <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-__---__-'�_y -----X--S------------------ Liquid Depth __#1�____________ <br /> +� Capacity . -0---__--__ Type C _ s.�< Material- - No. Compartments ---------.----------- <br /> Distance <br /> ._-. _ _ .Distance to nearest:' Well ------ +_______________ # d / <br /> ------Foundation i ---- --------- Prop. Line -,5—/ <br /> LEACHING LINE No. of Lines t7 <br /> [jd ----------------- Length each line-- �j- /-7 --- Total Length ------.--------•-- - <br /> pp r, <br /> 'D' Box Y_eA____ Typo Filter Material I(__.........Depth -filter Material __�I!-__________________I_______________ <br /> ----------- Property Line _ ---------- <br /> Distance to nearest: Wel! ___$�_______________ Foundation _l__________ ____._____ <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter _____________ Number --------- Rock Filled Yes ❑ No ❑ <br /> Water Table Depth ------------------------------------------------Rock Size <br /> to nearest: Well ________________________________________Foundation _________-____-_____ Prop. Line ________________._____ , <br /> REPAIR/ADDITION{Prev. Sanitation Permit C# ____________________________________________ Date ______:___________________________) <br /> SepticTank (Specify Requirements) --------------- ----------------------------------------------------- --------- --—--------------------------1--------------------------- <br /> Disposal <br /> -------- ----- <br /> Disposal Field (Specify Requirements) ____________ <br /> ----------------------------------------------------------------------------------------------------------------------------=----------------------------------------------------=------------------------ <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 /> Title Z <br /> {If other than owner) <br /> F R DEPARTME SE ONLY �7 <br /> APPLICATION ACCEPTED B '--- -- ----- - 'F - --------- ----- - ------ DATE ---- - --- -- ---/ ------ <br /> BUILDING PERMIT ISSUED ----------- r ---------- DATE ------------- ------ <br /> ------------ ------- <br /> ADDITIONAL COMMENTS '` ___ ______ _ <br /> --------------------------------------------------------------- ------------------------------------------------- <br /> ----------------------------------------------------------------------- <br /> -------------------------------------------- -- <br /> Fina! Inspection by: -- ---- -------------_- ----------------------------------------------------------------------------Date —73- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> �. E. H. 9 1-'b8 Rev. 5M <br />