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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> Permit No. <br /> (Complete in Triplicate) <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 .I 0 /e I- `�/rl C CEiVSUS�/TRACT - <br /> Owner's Name -- N- --------1°---------e0_V_�-�----------- ------- - ------_-------------------Phone •---------_.----_- <br /> Address ----- ----------------- Cit € <br /> Contractor's Name -----, 61C-------------------------------------------------------------License # ---------:-------------- Phone -------•---------------------- <br /> Installation will serve: Residence D<Apartment House,[] Commercial ❑Trailer Court ❑ <br /> Motel ❑ Other ------ ----------------------------------- <br /> Number of living units:---./ Number of bedrooms _-„ ____Garbage Grinder __________ Lot Size <br /> ----------- <br /> Water Supply..Supply: Public System and name -------------- ------------------•-------------------------------------------------------------------•---------Private ❑ <br /> Character of soil to a depth of 3 feet: SandK 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 public sewer is available within 200 feet,] <br /> PACKAGE TREATMENT [ ] SEPTIC TANK Size.______ _d_____._ -________ Liquid Depth __ ------ ----------- <br /> Capacity --------------------- Type -------------------- Material_-- _-- - No. Compartments ,t12--- <br /> Distance to nearest: Well _______ t___________Foundation ___/0_ _________ Prop. Line <br /> LEACHING LINE No. of Lines ------3--------------- Length of each line---��__� �d Total Len Q <br /> g �---- ----- Length --'���-.....---- V <br /> t { <br /> D' Box --� ____C <br /> .__ Type Filter Material ___ � _____Depth Filter Material __ rI ____ _________ ____`___._.____ Q� <br /> r <br /> Distance to nearest: Well .___ 4 <br /> ---____-___ Foundation -___16__r_________ Property Line ___ ______________ <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number ---------------------------- Rock Filled Yes .0 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) ----------------------- ------------------------------------------------------------------------------------------------------------- <br /> --------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------ 1 <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 /> By ------ ------------------------------------------- -----------------------•------------------------ Title ---.-------------------------------------------------------------------- <br /> (If other than owner) <br /> �RDEPA-RTMENT USE ONLY , <br /> APPLICATION ACCEPTED BY r,�� --- . . ------. QATE f �p <br /> BUILDINGPERMIT ISSUED ----------------------------------------------------------------------------------------------------------DATE --------------- -•--- <br /> ADDITIONAL COMMENTS <br /> ------------------------------------------------------------------ -------------------------------------------------------------------------------------------------------------------------------------- <br /> ---------------------------------- ------- ------------------ ------------------------------------------------------------------------------------------------------------------ <br /> ----------------------------- - ----------------------------------------------- ------ <br /> - - ----=------- <br /> Final Inspection by c-a_�- - - Date ----- ---� --- -------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M, <br />