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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> Permit No. <br /> {Complete In Triplicate) <br /> . <br /> . <br /> - " _/-. <br /> ..___... �,�.., Thls Permit Expires l Year From Date Issued Doti 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/LOCATIONo..:...'��`.. - -Irfel.................... -'' <br /> -............ ......................................CENSUS TRACT ..............-........... <br /> I Owner's Name ...............•---•..........�'............ <br /> �1 �• ................."......................Phone .................................. <br /> lel <br /> Address '' =" -� -•--.........A._.. City .11.! � `���................ ......... <br /> . <br /> Contractor's Name ---•-- .....................:-------.License #vZ71:,JYY--.. Phone <br /> Installation will serve: --`Residence XApartment House+] Commercial{]Trailer Court .0 <br /> Motel ❑Other ............................................. s <br /> Number of living units:.../._ - Number of bedrooms _X.....Garbage Grinder ell ._ Lot Size/ ............ <br /> Water Supply: Public System and name ........................----------------------_..._.:...__............................................_-....Private 21 <br /> Character of soil to a depth of 3 feet: Sand 0 Slit 0 Clay ❑ Peat❑ 'Sandy Loam fl Clay Loam ❑ <br /> Hardpan❑- Adobe;Z Fill Material <br /> ............ 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: t (No septic tank or seepage pit ,permitted.lf"public sewer is available within 200 feet,+ <br /> PACKAGE TREATMENT`,[ ] SEPTIC TANK I .S' <br /> Sze::"...---•-••...................•--•---•----..--. Liquid Depth _............:...... ...... <br /> Capacity TYPe,...........-•-----_. Material...................... -No. Compartments ............. <br /> DistaDistance. <br /> nce.to nearest: Well ....................................Foundation ............":....... Prop. Line .................._._. <br /> LEACHING LINEb j No. of Lines ----_-_--------------• Length of each line.................._--....... Total Length _........................... <br /> ." 'D' Box ............ TypeFiltei Material ....................Depth .Filter Material' ............... ..................... . <br /> Distance to nearest: Well _._.n_.... ------ Foundation ... Property Line <br /> SEEPAGE PIT [ ] {. Depth ._\. ............ Diameter <br /> °=-•--...... Number ---- . <br /> _. Rock Filled Ye$❑ No <br /> ' Water Table Depth ----------------------- -= hock Size _....... = - <br /> 'Distance to nearest: Well ...Foundation /Prop. line, <br /> REPAIR/ADDITION(Prev. Sanitation Permit<f -------------------------------------------- Date --------------- .................. <br /> Septic Tank (Specify Requirements( ...........................--•••--•--•-....._...... <br /> �..... ---- - • --------••---•-- <br /> pisposal�Field (Specify Requirements) � °Cff '.. . ............... <br /> .... <br /> ....................................... r e f---------------•:•._... ........ ........................ <br /> ,. f m <br /> ------------------------- <br /> --------------------------- <br /> r <br /> t � f <br /> (Draw existing and required addition on-reverse side) ' <br /> I hereby certify that,l`have prepared this application and that the work will be done In accordant' with San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health:Dlstdct. Home owner or licen- <br /> sed agents signature certifies the following: y, - <br /> "1 certify that in the performance of the work for which this permit�is issued, I shall not•emp!oyany person In suchmanner <br /> as to become subject to Workman's Compensation laws of California." <br /> i �:7, <br /> Signed --------- -•---•--- - <br /> ._.._ --•-- --- Owner ;' .� f • <br /> By ----------- <br /> ------------------------ Title _ �� �'- <br /> (If er than owner) _` <br /> R DE ARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ---------- -- -__-- DATE - sN+. : �.l_7 6.._.____-_ <br /> - --• -•------------ --------••---------.....__.._. <br /> BUILDING PERMIT ISSUED --• ` ---------_------ • ---....---DATE ---------------------••--- <br /> ADDITIONAL COMMENTS ............... --------------------------- <br /> -1 - <br /> ............................. ------------------ ---­-----------------­-- ---------------- <br /> -----------------------------------------• _ .. <° �. <br /> • :.-..._._... •--- •- ---------------------- ------------------------------------- <br /> ------------------ <br /> ----•--- -------- 3 <br /> ----- - - - - - - - <br /> i=ina! Inspection by: " `�'-.......... _.... Do�ie .. / � 7 <br /> EH 13 2h 1-6$ 3 �• SAN JOAQUIN LOCAL HEALTH DISTRICT — <br /> �.8/7h 31K <br />