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I <br /> FOR OFFICE USE: ` <br /> APPLICATION FOR SANITATION PERMIT <br /> ------------------------ <br /> Permit <br /> (Complete in Triplicate) <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 per to construct and install the work herein <br /> described. This application is made in compliance with County Ordinance No. 549 and existing Mules and Regulations: <br /> JOB ADDRESS/LOCATION __ +_Q_-f�---- Y--- -- -----------------CENSUS TRACT -------------.------------ <br /> Owner's Name -------------------- --------- -------------- -- ------------Phone------------------•---•-----•-------- <br /> • �t <br /> Address . j city - ------------------------------------------------ ---- <br /> ff .,. <br /> Contractor's Name _____- ___ , t�.c-r.��___.License Phone ___________________ <br /> Installation will serve: Residence Apartment House,❑ Commercial :❑Trailer Court <br /> 11 Motel ❑Other -------------------------------------------- <br /> Number of living units:-----r------ Number of bedrooms __ ---Garba e Grinder ------------ Lot Size ____________________________________________ <br /> Water Supply: Public System and name _____________ -_--._ Private ❑ <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Gay ❑ Peat❑ Sandy Loam Clay Loam <br /> 'i']'Hardpan [❑ Adobe'0 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"sepfic tank'or seepage..pit permitted•9f-public--sewer is available-within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] Size___ ''" �- - ------------------- Liquid Depth _________________--_----_. <br /> Capacity - ------------------ Type - ----- Material - ` No. Compartments ' ............... <br /> (Q� <br /> Distance to nearest: Well ____________________________________Foundation ----------------------- Prop. Line ------------------ <br /> LEACHING <br /> _____,_._- ______LEACHING LINE [ j No. of Lines ________________________ Length of each. line- ---------- -------------- Total Length ------..._--. ........ <br /> O <br /> 'D' Box ___ ------- Type Filter Material ____________________Depth .Filter Material ---- <br /> _ ---- ---- <br /> ___- ------------------------------ --- <br /> Distance to nearest: Well ________________________ Foundation _.____.______.__________ Property Line _-_-_--___.----___:____ <br /> "` Rork Filled Yes No <br /> SEEPAGE PIT [ ] Depth ----.i-------------- Diameter --------------- --Number ----------------- ---------- ❑ ❑ <br /> Water Table Depth ------------------------------------------------Rock Size -------------------------------- <br /> Distance <br /> ------------------------------Distance to nearest. Well ----------------------------------------Foundation -------------------- Prop. Line ....._..__._. ........ <br /> S <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ---------------------------______) <br /> Septic Tank (Specify Requirements) ------------ ---------------------------------------------------------------------------------------------- ------ - <br /> Disposal Fief. {Specify Requirements} -- [e ---- -p--Q---_-_---.E --���s=-__-.------ --.-------- ---------- <br /> -v --------------- / --------------------------------------- ----------------------------- <br /> ------------------------------------- <br /> ---- -------------------------------------------------=-- ---------------- ------------------------------------------------- ---------------------------------------- ------------------------- <br /> I (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 d in's Compensation laws of California." <br /> Signed ------- -------------- -----*owner) <br /> :18 ---0 -------------------------------------------------- <br /> ------ ---- ------ ----- - -------------------- Owner <br /> BY - Titl <br /> {If other t a <br /> FOR DEPA MENT USE ONLY <br /> APPLICATION ACCEPTED BY _ -___ ________________________ 7 <br /> -------------------------------------------------------• DATE l ----------- <br /> BUILDING PERMIT ISSUED -------------'_____--- ------ <br /> ---------- ---------------------------------- --- - -----------------------DATE - ---------- --------------- <br /> ADDITIONALCOMMENTS ------ ------ -------------------------------------------------------------------------------------------------------------------- --------------------------- <br /> --------------------------------- ------- - ----------------- - - ------------ - --- - -- - - -- - - �----- --------------------------- ---------------------------------------------------------------------- <br /> 7_4-7---7- <br /> Final - - <br /> �� -7- <br /> Finai Inspection by: --------------------------Date -------------------------------------------- <br /> SAN <br /> ------ ------------------------------------SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />