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FOR OFFICE USE. <br /> APPLICATION FOR SANITATION PERMIT <br /> ?. ... ..................... Permit No. .. .. <br /> (Complete In Triplltatel ' <br /> 1 <br /> This Permit Expires >I year Froin Date Issued Date Issued .-l._.�..... <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 coffTJ19nce with County Ordinance No. 544 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCA N ... .. . . - ---- <br /> ...............CENSUS TRACT . . <br /> Owner's Name ..- --- .............. -:! . . ---- . f......:. .Phone . .0.4?0 <br /> Address .. ---.-----------.:. -- -- CI .. .._....- <br /> Contractor's Name -- --------- --- <br /> ------ --------- ----.....................License # $V..... Phone / ��/ <br /> Installation will serve: Residence(Apartment House f] Commercial OTraller Court ❑ <br /> Motel ❑Other.............-_................__------ <br /> I 11 <br /> Number of living un'its:___-I... Number,,bf bedrooms ...�-Garbage Grinder ..._.... t Size .. -L4/_�-. ..........- ...... <br /> Water Supply: PubiiclSystem and name ....._ ................................................. at <br /> e 0 <br /> Character of soil to`a, epth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loom ❑ Clay Loam ❑ <br /> Hardpan' Adobe Fill Material ......__�.. If yes,type ............... ............ <br /> (Plot plan, showing size of lot, loc tion 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,( <br /> PACKAGE TREATMENT SEPTICTA. AIK _ _ <br /> -- - I � � ��... - Size------------------------•• � -•--------------- Liquid Depth . . . ...... � <br /> ..— Capac ty ._ ----•__-_-- ype �' . ..�. _ Material........ -•---.-.- No. Compartments -------------------- -� <br /> ... - .. .. <br /> Distaof No. <br /> nce to nearest: Well __. .........................Foundation ...................... Prop. line ...................... <br /> LEACHING,LINT; Lin <br /> 1 es ---------------------- Length of each line............................ Total Length .......................... <br /> D' Box ...... Type filter Material _..................Depth .Filter Material ................ <br /> 1 •-----••................... <br /> r Distance to nearest: Well ...................... . on .................... Property Line ......................... <br /> _ } Foundation <br /> ____ � ��,.��'""`�� --- Rock filled Yea ❑ No <br /> SEEPAGE PIT"['-J Watt�abl � :...:�Diamefisr-�-��lumber -----:--•......-•----.--- <br /> Sl'Table Depth . ........................... •................Rock Size ................................ <br /> Distance Ito nearest: Well ---------------------- --.--.....-----..Foundation ...-__---------- <br /> f <br /> _ Prop. Line ...................... <br /> OEFAIR/ADDITION'#Prev:,_Sdnitation Permit# .........................----.- <br /> ........----=-Date <br /> } <br /> Septic Tank (Specify Requiremonts�._..:......:........`:. ... - <br /> 4 <br /> r--.-... ..... •... -----•...... ............ .................. r <br /> Disposal -Field (Specify Requirementsj . ; •• •---• •------ " <br /> �nn <br /> r� R.�•.:�.e ..iCtX <br /> ---------- -•-------•------ -• ------------------------ -----• ---•---. ,..�................ .................................................... <br /> (Draw existinand req uired 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 o_f�,ihe San JoagGlnLocal Health:District. Horne 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, l shall not employ any person in such mariner � <br /> as-to become subject to Workman's Compensation laws of California." <br /> Signed __.. <br /> ..... -- ----------------- <br /> wner ` <br /> By ................. -c .. -----------------.------- Title ---.-_.... --- ............. ......... <br /> {If r tha �oWner) <br /> t �0�ARTME_NTONLY __ <br /> APPLICATION ACCEPTED BY ............ ----•--- .:_.. DATE <br /> BUILDING PERMIT ISSUED -------- ---- ---- -- DATE _ <br /> 1 <br /> ADDITIONAL COMMENTS ..-... _-.- <br /> -------------•---------- ••-------- ----- <br /> -------- ---------- --- <br /> ------------------ • - -------------------------------------•- --------..---------- --------------I..."--------y------- <br /> ------------------------•------........---...... .... . <br /> final inspection lay.: ............... . .. - - - - _--_------------- ...Date .... `..7 -..-5.-- .-..... l <br /> EH <br /> 13 .2 1-613 Rev. 5M SAN JQAG?UIN LOCAL HEALTH DISTRICT 8/74 3M <br />