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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT _ <br /> Permit No. <br /> (Complete in Triplicate) ...... <br /> ............................................. This Permit Expires I Year From Dote Issued <br /> Date 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 Ordinanq No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION - CENSUS TRACT <br /> Owner's Name . x!-�..................... : ......................................Phone .......I............................ <br /> Address ..... .c� 1.. .... ..City ............................................................................ <br /> Contractor's Name .......... ._✓L.'.`.'.. ........ ........•.................License # l8d. k Phone .............................. <br /> Installation will serve: Residence Apartment Houses] Commercial ❑Trailer Court ❑ <br /> Motel ❑Other ............................................ <br /> Number of living units:.--... .... Number of bedrooms 3...Garbage Grinder ............ Lot Size ............................................ <br /> Water Supply: Public System and name ..............................................................................................................Private <br /> Character of soil to a depth of 3 feet: Sand 0ilt❑ Clay [:] Peat[3 Sandy Loam ❑ Clay loom ❑ <br /> Hardpan Adobe '0 Fill Material ............ If yes,type ............................ <br /> (Plot plan, showing size of lot, location ofsystem 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 [ ] SEPTIC TANK I ] Size................................................ Liquid Depth .......................... <br /> Capacity .................... Type .................... Material...................... No. Compartments ...................... <br /> Distance to nearest: Well ....................................Foundation ...................... Prop. Line ......................P <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 Z <br /> SEEPAGE PIT [ ) Depth .................... Diameter ................ Number ............................ Rock Filled Yes ❑ No (:] ' <br /> Water Table Depth .....................Rock Size <br /> Distance to nearest: Well ........................................Foundation .................... Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ............................................ Date ..................................) <br /> SepticTank (Specify Requirements) ....................----------,..........................................................................................._................. <br /> e <br /> ...-.fie- yeTr. .. .1 L'T.-.:_.--�'�I_L.Y' EYP}rG.......................... <br /> Disposal Field {Specify Requirements) -���! °� ... n� � ........ <br /> ----/...`..... ,/Aa,,�jt;4t.;l =- - ---------------------------------------------•-•---._..........................................---•-•-•---- <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 licm <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 /> 01 <br /> By ........................................................... 4? :.J.L� �... Title . r es......................................... <br /> (If other than owner) <br /> �s FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ............�,.t .-... .... .......... DATE ......... --•-- <br /> BUILDINGPERMIT ISSUED .......... ................•---....----•---••-----..........--•-•-------------.DATE ........................................... <br /> ADDITIONAL COMMENTS ..............•................................................................... <br /> . <br /> ............................................................................................................................................................ ...... ................. <br /> ................. .................................. . . ................................................ <br /> FinalInspection by: ..................... . ..................•------•.................................................................Date ......1. 2 .... ..,7,5....._... <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 3-3 241.'68 Rev. 5M 7/72 3 X <br />