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�• i <br /> FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> --------------- _ Permit No. 7 _ 6S <br /> r (Complete in Triplicate) <br /> This Permit Expires ] Year From Date Issued <br /> Date Issued ---?k_,:� /--. ' <br /> --------------------------------------------------------- <br /> i <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 Rules and Regulations: <br /> JOB ADDRESS/LOCATIONO -- -- ------- ---------------------- - ----------------------CENSUS TRA -------------•--------------- - <br /> ••- <br /> Owner's Name --'--- f ----Phone --- <br /> Addressfl(-Y �— --- ----- I,/ ----------------------------- City ----------- ; -------------------------------•--------•-------- I <br /> Confiractor's Name- --------------------- License # Phone <br /> Installation will serve. Residence Apartment House-E] Commercial ❑Trailer Court ❑ <br /> a <br /> Motel ❑ Other -------------- ----------------------------- <br /> Number <br /> ---------------------------Number of living units:-----_/---- Number of bedrooms __.Garbage Grinder ------------ Lot Size <br /> Water Supply: Public System and name ----------------------------------------------------------------------••--------------------------------------Private I <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 /> 4 <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: INo 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 /> P Y -'--- '- YP -- N <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 i❑ \ <br /> Water Table Depth -------------------------------------------------Rock Size -------------------------------- <br /> 4 Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line --.------------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------- ----------------------------------- Date ---------------------------------- <br /> Septic <br /> -----------.--------------------- <br />?� Se tic Tank (Specify Requirements) _______-���-- -- --------V <br /> _1�c7C `_�`�_�--���, <br /> P p • Y q - � 'i �- <br /> Disposal Field (Specify Requir ments) �- ----- ' <br /> `rX / / <br /> � % -; <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 th i the performance of the work for which this permit is issued, I shall not employ any person in such manner <br /> as to beco e t ork n' Compensation laws of California." <br /> Signed - -------------------------------------------------- Owner <br /> BY --------------------------------------------------- -------------------- -Title --- ---- ----------------------- ----------------------- --------------- <br /> (If other than owner) # <br /> 1`011 DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY r' ------------------- DA�__ _. ----- <br /> BUILDINGPERMIT ISSUED ---------'----------------------------------------------------- - ----------------------=--------------DATE -------------•---------------- ------ ----- <br /> ADDITIONALCOMMENTS ------------- ------------------------------------------------------------------------------------------------- -----------------------------•-------------- <br /> ------------------------------------------------------------------------------- <br /> ---- ----- ------------------------------------------------------------------------------------------------------- <br /> ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------- <br /> ------------------------------------------- - <br /> Final Inspection by: ----- C-�---------------------------------- ----------------- -•-------------- --------------------Date ------ -- -- - - ---��--- --- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT G1-L <br /> F H 9 1-'68 Rev. 5M `��•! <br />