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�f01Z OFFICE USE, a' <br /> /� APPLICATION FOR, SANITATION PERMIT � 3_ Sys <br /> .................................... 1.:_ __...... .' N Permit No. _ <br /> (Complete in Triplicate) <br /> Date Issued .`............... <br /> ....... This Permit Expires 4ear From pate 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 /> f1I?.P N 7�e vz ...................CENSUS TRACT ....---------........._... <br /> JOB ADDRESS/LOCATION ....-.......7�C>.;-.��a--- , <br /> -#�7R•=�.5.. �� r� �............... <br /> Phone <br /> Owner's Name - -. .�Qt. <br /> Address -- ..-- ....... city <br /> Contractor's Name ........... .:. .° (t .rs€F__ ..5' t <br /> ...................License # --'` SF 3`F3... Phone <br /> Installation will serve: Residence [Apartment House❑ Commercial ❑Trailer Court ❑ <br /> ' Motel ❑Other .... -• •--------------------• -------- <br /> Number of living units:.......j.... Number of bedrooms-.._ .__Garbage-Grinder,............. Lot Size ... --••• ............ <br /> ' Water Supply: Public System and name ...............------ -...---------- -- --------- ------- ............................. .......Private j <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay E] Peat E] Sandy Loam ❑ Cloy 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. mustbe placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> i <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size.--'------------- Liquid Depth .......................... <br /> jCapacity ,. ..... ...... Type ...-................•Material_--._...--.... .--No. Compartments ......................V1 <br /> Distance to nearest. Well -_.._Foundation . .-_..._.___....._._ Prop. Line ......:............... J <br /> LEACHING LINE [ ] Na. of Lines ... -Length ofleach-line'....-... .. _:n.._...-Total 'Length ....................._---__.Q <br /> 'D' Box ...... ... Type filter Material --------------------Depth Filter Material ...................................... <br /> Distance to nearest: Well ...... ................. Foundation ......-._...........--- Property Line ........................ <br /> � <br /> SEEPAGE PIT ( ] Depth .. .. .. ........ Diameter . -_---- Number . ------ Rock Filled Yes ❑ No ❑� <br /> A. Water Table Depth ----..__.._:....--••.............................Rock Size -.-------...---......----------- <br /> Q <br /> Distance to nearest: Well ........................................Foundation _..- .............. Prop. Line .__......._........ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ---.------ ----...•----------- --•----- Date ...------------___.----------) <br /> Septic Tank (Specify Requirements) .... ..... ......................... ,-----•--- • --•----- • --......---...__..... <br /> Disposal Field (Specify Requirements) ......... Q r ' ' '�' '" .^Q-'........:.............. .:. <br /> �gy%!A) _)01 �-..-•---..._... •-• ----------_ ------------------- <br /> ..----..... - . ...................... ... ----...a ..- <br /> _...._-- --- ------------ --._.. -- --.._....-- ...----._....- <br /> (Draw existing and required addition on reverse side) ^» <br /> 1 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 Compensation laws of California." <br /> ` Signed .:.. ....... ..... -. --------- -------------- - ---------------------- Owner <br /> . .Title ,...... .......I—-..._...._......_..._.. <br /> {I other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ...-... .. ..� - DATE - ../. ...2 ._ ...... <br /> BUILDING PERMIT ISSUED .-_- DATE . ..-_•...................••----._....._._. <br /> ADDITIONALCOMMENTS ------------- -•--- ------.........-------------_.. .......... ............--..---­---.............--------- ------ ------------- <br /> ....----••. .............................. ----------------.............•-----•-•............._..---------- ---- •--------------------- ......... <br /> ............:............................ --- <br /> ----..... ..-------------- ----- <br /> ................ - <br /> Final Inspection by. .......... --- - ----------------------------- <br /> ------------------------------------•---Date ....f_. ...� �:.� <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT } / <br /> l / !/ 72314 <br />