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FOR OFFICE USE: 'i !i - <br /> APPLICATION FOR SANITATION PERMIT <br /> Permit No. <br /> ete . 3•• <br /> ` (ComplIn Triplicate) <br /> .........................::................:L.., /3 ... <br /> dd Date Issued . :........�6 <br /> 9� .,, This Permit Expires 1 Year Frons Date Issued <br /> ..........: . <br /> Application is hereby madto the San Joaquin Local Health District for a permit to construct and Install the work herein <br /> described. This applicatiori!�is made in compliance with Coun y Ordinance No. 549 and existing Rules and Regulations: <br /> l I� <br /> ..... <br /> . ._�.�... ....._.._._........._... . ..................................CENSUS TRACT <br /> JOB ADDRESS/LOCATION !� -• <br /> C►wner s Name ... ... . ..... .............. :.....................Phone (.. ... <br /> Address ............. ..........�...............- ......- ........ City .. ....... <br /> Contractor's Name ....... .. .i!.......� ..:.. °� ..... cense # .......................... Phone G9.:,........y­ <br /> Installation will serve: Residence'KApartment House C] Commercial❑Trailer Court 0 <br /> h <br /> Number of bedrooms ; arba a Grin ....................................Ii <br /> Motel ❑Other .......'..........: <br /> ' �; der � Lot Size �4� � <br /> Number o#living units:_.. � .._ ... g -...... . ' _.... ---...... <br /> Water Supply: Public System and name ..... ........t ..... ..................._................................I............. . .Private ❑ f <br /> Character of soil to a depth of 3 feet: Sand❑ Slit[3 Clay ❑ Peat❑ Sandy Loam ❑- Clay loam <br /> Hardpan❑ Adabe; F111 Material ............ If yes,type ............................ <br /> i �p <br /> (Piot plan, showing .slze of lot, location of system in relation to wells, buildings, etc. must be plaVf <br /> �on reverse side.) <br /> NEW INSTALLATION- ' (No septic tank or seepage ;pit permitted if public sewer is available within 20leet;) ✓ <br /> PACKAGE TREATMENT ( ] SEPTIC TANK I ] � Size......................... --...... Liquid Depth .......... ............... <br /> . <br /> Cc�padry :............ ...... Type --..... ......... Material...................... -No. Compartments .................. <br /> Distance to nearest.• Well .........Foundation ___... Prop. Line ................ <br /> l <br /> LEACHING LINE { ] No. of Lines . ... Length of,each line.................... .. Total Lengthy <br /> l D°'Box Type Filter Material ...Depth Filter Material <br /> . <br /> G Distance to nearest: Well . Foundation ... Property Line i <br /> f <br /> SEEPAGE PIT [ ) Depth ..................... Diameter ............. Number ............................ Rock Filled Yes ❑ No i❑L` <br /> W9ter Table Depth ............ ........Rock Size ..... j <br /> Distance to nearest: Well " .......................Foundation ..... Prop.' Jne .........-------_-•-. <br /> REPAiR/ADDITION(Prev.•Sanitation Permit ` :--.: 1 ' <br /> ..�................................. . Date .............---...._...._.__._... ; 1 <br /> )Septic Tank (Specify Requirements) -- .? .. -------------=--- .....:......................_.:,.........._............_..`._. <br /> r <br /> Disposal Field (Specify' Requirements) ,, p !� <br /> a <br /> ............................................................•-.....--...... ...... . ....... .. •-- ............ <br /> E . ' <br /> {Draw existing and required addition on reverse side) <br /> f I hereby certify that 1 have prepared this application and that the,work will be done in accordancewith San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San.Joaquin Local Health District. Home owner or lice!:,, <br /> sed agents signature certifies the following: �' <br /> "I certify that in the perforin ce of the work for which this permit Is Issued, I shall not employ any person In such manner <br /> as to become s )ect t Wo n�afn'�s�C�a�m ensatio laws of alifornio." ! <br /> Signed .............. ..�._.-_.. Owner <br /> By --------------------------------------JJ.ff-:. xitle -------... �.......'... �.......... .............. <br /> 'll <br /> (if other thari'ownerl Y <br /> FOR DEPARTMENT Ul ONLY a <br /> APPLICATION..ACCEPTED BY ...................................... -•--- �.--- r .. DATE .../../5�-!-�►...... <br /> ...............`... <br /> BUILDING PERMIT ISSUED. <br /> ADDITIONAL COMMENTS! I <br /> ------------------- 'L... ...................................... ---... _/'. ...... =Vis......------• <br /> .......................................... ............................................. .......--•-------..._...._..._... ------............................- ...... ..................... <br /> !M <br /> .. <br /> 'M !M <br /> .... ....... <br /> Date <br /> Final inspection by: ......._...M....................... _.... .. _ .... ...... ..... ............ ....... <br /> SAN JOAQUIN 'LOCAL HEAL DISTRICT <br /> :. w <br /> 13 24 a_,tea a--- =AA <br />