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FOR OFFICE USE. <br /> APPLICATION FOR SANITATION PERMIT — �j 3 <br /> (Complete in Triplicate) Permit No,. ________________ ___ <br /> __________________________-_._._.___-__ nt------ This Permit Expires 1 Year From Date Issued Date Issued /_ v <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 At/,Yy7l-. �-- --- p__ PCQ�IL�9-----� <br /> - P-----------------------CENSUS TRACT -------------------------- <br /> Owner's Name d�� - ?/---------Y �- O__Yl/-----------------------------------------Phone ----------•---• -------------------- <br /> Address -----��mv------------------- - City _,-S.t__�6i�1-FVlY-- --------------------------- <br /> Contractor's Name (--___-. ,l ---------------License # 122,OOT2--- Phone d "- <br /> Installation will serve: Residence INApartment House❑ Commercial ❑Trailer Court ;❑ <br /> G <br /> Motel ❑_Other ----------------------------------------------- <br /> Number of living units:---/------ Number of bedrooms ----Garbage Grinder�I�__.__ Lot Size _' 0_.___/ �fr" ...... <br /> [ Water Supply: Public System and name ____________________ . ________Private {� <br /> Character of soil to a depth of 3 feet: Sand'❑ 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,[ Nt <br /> PACKAGE TREATMENT [ ] SEPTIC TANK,[ ] Size------------------------------------------------ Liquid Depth -------------------------- <br /> Capacity ----- ---------- -- Type -------------------- Material---------------------- No. Compartments -------------- <br /> Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ---------------------- �� <br /> - <br /> { LEACHING LINE { ] No. of Lines ------------------------ Length of each fine_________ -- _ <br /> -------------- 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 <br /> Water Table Depth ------------------------------------------------Rock Size -------------------------------- <br /> Distance <br /> ---------------------- •-----Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line '.-__.--_---__-_._---- <br /> I REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ---------------------------------- <br /> Septic <br /> -_---_- -_____________________Septic Tank (Specify Requirements) ----------------------------------------------------------------- <br /> --­---------------- <br /> ----------- <br /> Disposal <br /> ---------- <br /> Dis osal Field (Specify Requirements) __ _ e . 0_ __ ___ ` <br /> P ( p Y q 1 �r�---�-- ��jr`�....._1 ��-----D_�1----����--/-�llV�--/-�lr�y�'-�1--�--------- <br /> t <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 <br /> I ompen "ti laws f California." <br /> Signed - ----------------------- --- -- --------------- <br /> Owner <br /> v <br /> By --------------------------------------------------------------- ------------------ -Title -------------------------------------------------- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ----------------------------------•----------------------- ----------------. DATE __- 01------------------- <br /> BUILDINGPERMIT ISSUED ----- -------------- ----------------------------------------------------------------------- -------DATE ------- ----------------------------- <br /> ADDITIONAL COMMENTS . <br /> -- ----- ------------------------------- <br /> - -------- ----- -------------------- - <br /> ------------------------------------ <br /> Final Inspection by - Date <br /> SAN JO UIN LOCAL HEALTH DISTRICT <br /> �ap <br /> `^f-,H:,,9 1-'68 Rev. 5M <br />