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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> ------ -- 1/- -------------- - a_S <br /> - Permit No. <br /> F (Complete in Triplicate) <br /> ---------------- This Permit Expires 1 Year From Date Issued ©ate Issued <br /> I Application is hereby made to the Son Joaquin Local Health District for a per to construct and install the work herein <br /> I described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION . ------ --- ------ �-=---'' f --------------CENSUS TRACT -------------- ----------- <br /> Owner's Name --------• ------------- ------- --- --- = Phone � _ _Y Q ' <br /> ------------- -- <br /> Address ---------- 17:4�__ _ .' <br /> Z ' _- -- City _1-- -------- <br /> ---------------- ----•-------- <br /> Contractor's Name ________________ .______ ____ <br /> ---------License # .i�/�- -- Phone "Zw__3,1 <br /> Installation will serve: Residence ❑ Apartment House❑,Commercial :❑Trailer Court ' <br /> Motel ]Other// <br /> Number of living=units:_______ Number of bedrooms ____,___Garbage Grinder ---------- Lot Size -_-------,------------------ ................ <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 /> `t Hardpan ❑ Adobe*Fill Material ____________ If yes,type-----------__--------------- <br /> L ..t, - <br /> (Plot plan, shkowing 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,) 4 <br /> ., V <br /> PACKAGE TREATMENT [ ] SEPTICTANK><' Sizo__4/7z,-5x __________________ Liquid .Depth .------ ...... <br /> Capacity --- Type = 4a Material__ °? _____ No. Compartments ' <br /> Distance to nearest: Well -__S?�______________ __ Foundation _.11.-___________ Prop. Line <br /> LEACHING LINE r DQ No. of Lines -------/-------------- Length of each line.___._--�,_0__--_.____ Total Length <br /> j D' Box Type Filter Material Depth Filter Material ____/ _-�____ _____`_________________ <br /> + Distance to nearest: Well __ __ _......... Foundation ________ Property Line �!_�__-__ � C <br /> SEEPAGE PIT Depth _Q2_S_________ Diameter ------ Number ___________ _____________Rock Filled Yes No i❑ <br /> Water Table Depth --------7�------------- ------------------Rock Size ---- �'� "'r1 <br /> �r <br /> Distance to nearest: Well ----M_63_________________........Foundation _/400-------- 'Prop. Line <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------j <br /> SepticTank (Specify Requirements) --------------------------------------------------------------------------------------------------------------.------------------ ---•---- <br /> DisposalField (Specify Requirements) --------------------------------------------------------------------------------------------- --------------------------------------- <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: 4 <br /> "I certify that in the performance of the work for which this permit is issued,'l shall not employ any.person in such manner <br /> as to become subject to �rk n's Compensation laws of California." i <br /> Signed l = -= � �--- Cr Owner <br /> B --------------------------- <br /> (If '� <br /> Y ----- -------- Er ----------------- Title -- . ------- <br /> other than owner) <br /> TMENT USE ONLY <br /> APPLICATION ACCEPTED BY --- -- q �3 <br /> ----- --------------------------- DATE ----/--- <br /> BUILDING PERMIT ISSUED ----------- -- -- ----- ---- -- ---------------------------=----- --: ____DATE ---------------------------------------••--- <br /> FADDITIONAL COMMENTS �---- ------f --- - ------ --=----------------------------------------- ---------------------------------------- <br /> ��ztie-��, -- - ------ --------------------------------------------------------------------------------------------------------------------- <br /> --------------------- -- --------------------- ----- - --- -------------------- ----------------------------------------------------------------------------------------------------------------------- <br /> ----------------------------------------- -- -- -- - - -------------- -----------------------------------------------------------------------------------------------------•--------------------- <br /> Final Inspection by: - -------------------------------------- Date `=.,�G�_�iY <br /> ----------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M �� t <br />