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FOR OFFICE USE: <br /> y APPLICATION FOR SANITATION PERMIT <br /> ------------------------ ------ Permit No. <br /> (Complete in Triplicate) <br /> Date Issued <br /> -------------------------------------_.-"______---__- This Permit Expires I Year From 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 --------------------- -------------------- -- ------ - -CENSUS TRACT -------------------------- <br /> Owner's Name .-Aw----j -------------------------------------------------------------------------- -------Phone- -' <br /> Address ----- --- ------ sAM—A---------------------=------------------------------------------------- Cit <br /> Contractor's Name -� --------- C'----------6_,ZZ s----------------- <br /> --------------------------License # 1,?2-SV_3-_ Phone�_,'�:r�?--.__ <br /> Installation will serve: Residence O-Apartment House❑ Commercial ❑Trailer Court i❑ <br /> Motel ❑Other -------------------------------------------- _ <br /> Number of livingunits:-- Number of bedrooms r <br /> �.___-__ "-_�_---Garbage Grinder ��/f)-- Lot Size ,�-�X"-1�-�-----_-.- <br /> Water Supply: Public System and name ---------------------- ---------------------------------------------------------------------------------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam 0 Clay Loam C1 <br /> Hardpan ❑ Adobe M— Fill Material --- ------ If yes, type ---------------------------- (1� <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---------------------------------------- ----- Liquid Depth -------------------------- <br /> Capacity -------------------- Type -------------------- Material---------------------- No. Compartments ...................... <br /> Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line -------------:..----_. <br /> LEACHING LINE [ ] No. of Lines ------------------------ Length of each line---------------------------- Total Length ------.----__-............. <br /> 'D' Box ------------ Type Filter Material --------------------Depth Filter Material ------------------------------------- ...... <br /> Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line _-_-_-_-_-_.---_.---. <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ------- -------- Number ---------------------------- Rock Filled Yes ❑ No 0 <br /> Water Table Depth -------- ---------------------------------------Rock Size ------------------------------- <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) <br /> SepticTank (Specify Requirements) -----------------------------------------------------------------------------------------------10----------;---------------- <br /> N <br /> Disposal Field (Specify Requirements) ---_�� -.�' ------ 1� �1 ---9--- - ----- �j-------------- <br /> - <br /> -------------------I----------------------------------------------------------- ----------------- ----------------------------------------------------------------- <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 subl to Workman's Compensation laws of California." <br /> Signed . r-r __ -_.t --------------------------------------------- <br /> Owner <br /> BY --------- --------- ----------------------------- ----------------------------------------------------- Title ------------------------- - <br /> - ------------------------------------------- <br /> (If other than owner) <br /> i/ FOR DEPARTMENT USE ONLY / <br /> APPLICATION ACCEPTED BY - -G ----lx ------------------------------------------------------------ <br /> --------------------------------------- <br /> DATE { c' ��`� r� --------- <br /> BUILDING PERMIT ISSUED ---------------------------- ---- ------=--------------DATE ------------------------------------------- <br /> - <br /> ADDITIONAL COMMENTS <br /> - ------------------------------------------------------------------------- --- ---- <br /> --------------------------------------------------- ,/ <br /> -- ---------------------------------------------- f - ------------- 7 <br /> ------------- <br /> - - <br /> ------=------- <br /> ------------------------------------- --- ----- --- --------------------------------------------------------- ----- --- -- ------- -- -- --- -- ----11 <br /> Final Inspection by: -- - - - -- Date l <br /> SAN JOAQU11v LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />