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FOR OFFICE USE: <br /> ------------------- APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit No: <br /> - -------------------------------------- This Permit Expires 1 Year From DatIssued <br /> - e Date Issued ��74 <br /> Application is hereby made to the San Joaquin Local Health District for a <br /> permit to described. This application is made in compliance with 7Cnty Ordinan a No. 549 and ex stingnRulestalndtRegularionsrein <br /> P ' <br /> N. _ .. . <br /> JOB ADDRESS/LOCAT <br /> D/ . <br /> Owner's Name <br /> CENSUS TRACT <br /> --------------- ----- <br /> Address .____.._._ <br /> ---Phone �a --�S-7` <br /> ---------- -------� <br /> City _ t <br /> - <br /> Contractor's Name - - i <br /> --------- ---- ------.License # <br /> rte' `{64 <br /> Installation will serve: - -�-�-- ----- - -- Phone -_-- -_ --Q_�--_-_ <br /> Residence Apartment House❑ Commercial ❑Trailer Court ;❑ <br /> Motel ❑ Other. <br /> -------- - - ------------- - --- <br /> umber of living units:------ ----- Number of bedrooms ___ ___-Garbage Grinder -__._-_____ Lot Size __--_lL - •� <br /> Water Supply: Public System>and naive.____-______________ <br /> pp Y- ----------- <br /> +a - - ----------------------------------------------- --------: Private I <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay peat Sand Loam • I a_ I <br /> (]iV. Clay Loam ❑ <br /> Hardpan ❑ Adobe ❑ Fill Material -------- <br /> 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: ' <br /> (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC <br /> TANK [ Size- <br /> ------------------ <br /> Size -='--------f-F---- -------- <br /> Ca acitY Type ia � <br /> - 'Materl ; ----------------- . o <br /> mprtments- t <br /> --= = <br /> Distance to nearest: Wei! ___---____- ' <br /> ------- Foundation _.-------------------- Prop. Line.------------_-- Gi <br /> LEACHING LINE __ <br /> [ ] No. of Lines ------------------- ---- Length of each- (ine---------------------------- Total Length -------•-------•-----=---•-- <br /> } 'D' Box ------------ Type Filter Material __ f <br /> -------- <br /> _-_-___-Depth Filter Material f <br /> -----=------------------------- <br /> Distance to nearest: Well _-_-___________________ Foundation ------- _-_- _-- <br /> -- Property Line.,----•----------•- -• _ <br /> SEEPAGE PIT r <br /> [ ] Depth ____________________ Diameter Number .____----__-__- --____ -_-- Rock Filled Yes [I No <br /> Water Table Depth --- -----•--------Rock Size - I <br /> Distance to nearest: Well _--____---_---- kV <br /> _--__ <br /> ------ Foundation -------------------- Prop. Line -------•----- a <br /> REPAIR/ADDITION(Pri v. Sanitation Permit# ____________________ <br /> Septic Tank (Specify Requirements) ---------------------------- _ <br /> - <br /> ---------- ---------- <br /> J f <br /> �. <br /> Dispose( Field (Specify Requirements) ----------------t------------------------------- <br /> g <br /> -------------------- <br /> V _____________________________ <br /> -------------- -----------I----------------------- -- --- -- <br /> (Draw existing and required add!-t-i--o-non reverse side) ' <br /> I hereby certify that I have prepared this application and that the work twill 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 /> "1 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-W.,orkman's-Compen3ati.on--laws-of California." ---- -- .«- --_ - _ _ <br /> Signed ----------- --- <br /> - -- ----------------------------------- --- Owner <br /> BY -------- --- .....= --------------------------------- Title -�') � ------------------------ <br /> FOR <br /> i{lf o than owner) � ---- ---- ---------- ---------- ------- <br /> k FOR .DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY .C�'_ -__- <br /> -- ------------------------------- ---------. DATEZ- <br /> BUILDING PERMIT ISSUED --- ----------- `--------- - ------- -------- -------- �------ <br /> DATE --------------------------- <br /> - <br /> ------------ - <br /> DITIONAL COMMENTS ------'.;� ----�� --------- - - ----- --------- - ---------- ----- - --------- € <br /> ------------------------------------------- <br /> --------------------------------------------------------------------- <br /> ---------------- <br /> --------------------------------------------------------- ------------------------------------------------------------ <br /> -------------------------------------- <br /> --------------------------------- -------- <br /> -----------------------------------------------------------------=------------------------------------------------------ <br /> ------ ------- <br /> ----- ------------------------------------------------------------------------------------ <br /> -- ---- <br /> Final Inspection by: -- -------- '_-------�.--- <br /> O <br /> r : <br /> - - - ----------- -.Date /z--- �a- - - f-- ------ -- <br /> p N JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />