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N. <br />` ' .. OFFICE USE: <br /> � f• APPLICATION FOR SANITATION PERMIT . <br /> i 7 �y <br /> (Complete in Triplicate) Permit No. o.._--------------- <br /> -------------------------- <br /> -------------------------- - ------------------ <br /> - ---------------------------- <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 M`dde in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> - <br /> JOB ADDRESS/LOC TION % I -- -- ----------------------------------------------- CENSUS TRACT _ <br /> Owner's Name Ph ne."-��� yS� <br /> cc�� <br /> Address coS_ _ _ .~'� -- ----- City . ---- ----- . . <br />' Contractor's Name . _-_ �_--.License # - ISL . - Phone _f`�l �zl� <br /> Installation will serve: ResidencegApartment House❑ Commercial ❑Trailer Court ❑ <br /> Motel ❑Other ----------------------=--------------------- <br /> Number of living units:---- .__ Number of bedrooms +z7_2-.___Garbage Grinder ----------- Lot Size ---7!f, -� <br /> c <br /> Water Supply: Public System and name ------------- -------- - <br /> . - --------------------------------------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam;❑ <br /> Hardpan ❑ Adobe Fill Material•_-a------- 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 septi ctarik or seepage pit permitted if public sewer is available within 200 feet] <br /> PACKAGE TREATMENT [ ] SEPTIC TANK i[ ] 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 -----------r___=____Depth Filter Material -------------------------------------------- <br /> Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line -------------------- -- <br /> SEEPAGE PIT [ ] Depth ---j-------------- Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No (3 <br /> Water Table Depth ------------------------------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ------------------_.-- <br /> REPAIR/ADDITION(Prev, Sanitation Permit# -------------------------------------------- <br /> Date ---------------------------------- <br /> Septic <br /> ---------------------------------Se tic Tank JSpecify Re uiremerts) } <br /> _ - -------------------------- ----------------- I <br /> Disposal Field {Specify Requirements} - - ----.---- -"_- -- - -- --- ----------- - -- ----- ----- - --- a - <br /> ,j , --- --------------------- -------------------------------------------- <br /> -- <br /> ------------------------------------------- <br /> --�-�-- v - � =�--- - ------------------------------------------ <br /> i <br /> ��{D a�ng and required additi non reverse side) <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with Sar+ 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 he work for which this permit is issued, I shall not employ any person in such manner <br /> as to b o s jec tow��_ <br /> mpensa i ws of California." 4 <br /> Signed - ------. -- --------- Owner <br /> BY ------------- ----------- -Title ------------------------ -- -------------------------------------------- <br /> (If } <br /> ' other than nero�G") <br /> AIRTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ------ - ------- --- --- -- -- - ----------------------------------------------------- DATE ------------- 4 <br /> BUILDING PERMIT ISSUED -- ------ <br /> - ------ - ------ - - -------- ------------ ------ ------DATE ---------------------------------------- i. <br /> ADDITIONAL COMMENTS ---- - -- -------------------------- --------------------•--------- <br /> ----- --- <br /> h _ _____ _-.___ __moi �„-________--"_______�____________"_____________________"____.__.____________-_-"_____.________._".__"________________-------------------------- <br /> --------- ----_/ f ---------------------------------- ------------------------------- --- --------------------------------------- ------ <br /> --- ----- <br /> � <br /> i <br /> -------------------------- --- ------- <br /> Final Inspection b ' -- -- Date .__._��L. <br /> U <br /> 4 I JOAQUIN LOCAL HEALTH DISTRICT # <br /> E. H. 9 1-'68 Rev. 5M (f <br />