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FOR OFFICE USE- � 4 <br /> APPLICATION FOR SANITATION PERMIT � <br /> ---------• Permit No. <br /> (Complete In-Triplicate) <br />..........,.­----------------------------�%............ - ' <br /> ......................... This Permit Expires 1 Year From Date Issued <br /> Date Issued ..Z. �. . J <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/LOCATION ...4?. -.!�+ ... -..�lf /t!rP. ../��u`.:...........................CENSUS TRACT .......................... <br /> Owner's Name � �/ ---•--- ......................................._.......... ..'................Phone <br /> .... <br /> Address . . .... a14_e ...... .. . .......... ........ ...................................... City ......-----•. ..........._.........._ . <br /> Contractor's Name .......4e/1T-.�.P1,r .......................................License #,97/...0.,3.?... Phone <br /> Installation will serve: Residence Apartment House f] Commercial ❑Trailer Court 0 <br /> Motel ❑Other <br /> Number of living units:__/------- Number of bedrooms .-3......Garbage Grinder I. -I't.. Lot Size ...................... <br /> Water Supply: Public System and name ............. � ..Private$ <br /> Character of soil to a depth of 3 feet: Sand 0 Silt❑ Gay ❑ Peat❑ Sandy Loam ❑ Clay 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. 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 ( j SEPTIC TANK{ j Size................................................ Liquid Depth .......................... <br /> Capacity ---•---- ---------_ Type ... Material......---------....... No. Compartments ....,................. <br /> � <br /> Distance to nearest: Well ..___Foundation ...................... Prop. Line ......................� <br /> LEACHING LINE ( j No. of Lines ---------------_--___ Length of each line............................ Total Length ............................ 0 <br /> D' Box Type Filter Material ........Depth Filter Materia} <br /> Distance to nearest. Well ---------------------_ Foundation ........................ Property Line ........................ <br /> SEEPAGE PIT ( j Depth Diameter ................ Number ............ ............... Rock Filled--,Yes © No 0 <br /> Water fable Depth ................................................Rock Size -----------•---•-•..... ........ <br /> Distance to nearest: Well ..........................Foundation .................... Prop. line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date .... <br /> ..7............................) <br /> Septic Tank (Specify Requirements) ----------------------------------------------d! ----?` .�.+./.._....�...../ __...----.......... <br /> Disposal Field (Specify Requirements) __/ -/. ��'�i------ - - -1�/G f ' '.4/Z10......................... <br /> 47-7----------------------------- <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 Son Joaquin Local Heal*.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 /> By -------------_--------------- C-------------- ....... title C.' ��'r�'" � <br /> (ifo than owner) <br /> R DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ----- ------------ ------------ DATE1' <br /> BUILDING PERMIT ISSUED _-- ----------------- ------DATE ................... ...................... <br /> ADDITIONAL COMMENTS -----------------------I----------------.................................................. <br /> ---------- •-------•• -••---.--------------------------•-------- --- ------ ------------••--- -- ------. ------ -----• ---.... ---------...._...--------------------�-� <br /> -----------------------•-------....--...._............-- - -------- -----------. -- --•- --•--------•---•-------------•----..._._------------ - -------- <br /> Final Inspection b .......Date _...f....�'._ <br /> EH 13 2h 1-68 I;ev. 5m AN JOAQUIN L AL HEALTH DISTRICT 6/7h 3M <br />