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FOR OFFICE USE: <br /> - APPLICATION FOR SANITATION PERMIT <br /> ---------- ------ --------- ------- Permit No. <br /> (Complete in Triplicate) <br /> ---------------------------------------------------------- <br /> --------------------------------------------------------- This Permit Expires ] Year From Date Issued <br /> 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/LOCATI N _ �� _ �.-- �-- ----------------------------------------------------CENSUS TRACT ---- - --7-_-._-.-""_ <br /> . Zll7LI_ ......_ <br /> Owner's Name . . - -------------- - {f\------------------- ----------------Phone ------------------------------------ <br /> p. .C'L4 __ j_P_'_ p <br /> Address ----- ----- / 'ted----- ---- _ �7 City ifa---��--------------------------- -------- <br /> Contractor's Name ------ - `1--- /Q ` °`�-esz..License # Phone <br /> --- <br /> Installation will serve: Residence L�Apartment House ❑ Commercial ❑Trailer Court ;❑ <br /> Motel ❑ Other _.------------------------------------------ <br /> Number of living units:_.._`___ __ Number of bedrooms _______Garbage Grinder ------------ Lot Size ______--__________________________________ <br /> Water Supply: Public System and name ------------------------------•-------------------------------------------------------------------------------Private <br /> Character of soil to a depth of 3 feet: Sand"❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam J� Clay Loam <br /> Hardpan❑ Adobe ❑ Fill Material ____________ If yes,type ___________________________ <br /> (Plot plan, showing size of lot, location oftsystem 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 /> � S <br /> PACKAGE TREATMENT ( ] SEPTICTANK;[� t Size___5�-_ ___ __1____ S------------- Liquid Depth ____ __________________ V <br /> Capacity '•_ts! <br /> TYP �2yz+>` ----- Material--- ....._ No. Compartments ----... -.•-•.�Distance to neaWell,____ Foundation ...... _-V-----______ Prop. Line ------- <br /> LEACHING LINE s -----"- <br /> L� No. of Line) ------- ---- Len -- <br /> Length of each line._-_-- --- - --____-- Total Length ------ <br /> 'D' Box ----- Type Filter Material ----S__Ri_------Depth Filter Material ------�1._jr___•-_____-_".--__-..•.•-. <br /> Distance to nearest: Well ---------SO--------- Foundation -------/©_............ Property Line ------ ______________ <br /> [� Depth ------tQ_--------- 4Aameor- Z�X_ ` Nvniber --------21'--------------- Rock Filled Yes [ No i❑ <br /> ` Fr �} ;t <br /> Water Table Depth ---------------- Q f Rock Size -- 1 /- ------ \ <br /> Distance to nearest: Well ------------sS 6._ ________________Foundation ------L.0_'____ Prop. Line _______-�.__-_____-.-_ <br /> REPAIR/ADDITION(Prev. Sanitation Permit e# -------_------------------------------------ Date ___-__--______----_---____________) <br /> SepticTank (Specify Requirements) -- --------------------------------------------- -------------------------------------------------------------------------------------------- <br /> Disposal Field (Specify Requirements).-------- °------------=-----`------------------------------------------------------------------------ ----•--------------- <br /> --------------------------------------------------------------------------------------- ----------------------------------------- -----------------------------------------------=------------------------ <br /> ------------- ------------------------------f- ----- - <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 /> - - ----- - --- <br /> BY --- ----------------=---------------------------------------- Titlea_ <br /> (If other than owner) <br /> f ------------------------ <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ---- <br /> ----------------------------------------- DATE /O <br /> BUILDINGPERMIT ISSUED --------------------------------------------------------------------------- -----------------------------DATE __.--------------------------------------- <br /> ADDITIONAL COMMENTS - <br /> -------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------- <br /> --------------- <br /> Final Inspection by: ---------------------------------------------------------------------------------------------------------------------- ------------ <br /> '-------------�----- ---------- Date - �, <br /> SAN JOAQUIN LOCAL-HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />