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f FOR OFFICE USE: - <br /> APPLICATION FOR SANITATION PERMIT <br /> ' Permit No. <br /> (Complete in Triplicate) <br /> This Permit Expires. Year From Date issued <br /> Date Issued <br /> ..... -..c3d..Z.. <br /> ........... ................................... . <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/LOCN - .a ..�..... .'..CENSUS TRACT <br /> Owner's Nome .. -- ....................-:........ � o <br /> 0 . ... <br /> . ..... <br /> -. <br /> y , <br /> Address ...7+! 't ...�(..��... �-�' ............ 'City. .. .._.. .... .. <br /> - •...... Phone ..... ...............: <br /> Contractor's Name ......:.....��--=------------------------------------------•-•--• ---------....'..._.....License # .:. <br /> Installation wilkserve:..*, «� ;Residence—] Apartment House m rcia railer Court <br /> Motel ❑Other.:... ... <br /> Number of living'-Units:..:.......... Number of bedrooms.............Garbage Grinder............. Lot Size ....,.-_......__-------- ................... <br /> n <br /> Water Supply: Public System and name ----------------- ............................. ----------------------- - -•-•--------- Priva �_ <br /> � - •1111.- <br /> ... - to <br /> Character of soil to a depth'of 3 feet: Sand Velsilt❑ Clay, ❑ 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, building's, etc, must be placed on reverse side.) <br /> i NEW INSTALLATION: (No septic tank or seepa pit permitted if public sewer is ovaildble' within 200 feet,) <br /> . � u <br /> PACKAGE TREATMENT [ ] SEPTIC TANK, Size.....-.1.:........:.:' _.......... ........... Liquid Depth . ..-.._............ <br /> iCapacity, dYp Materiae! mpa s <br /> No Co rtment . <br /> Distance to nearest: Well .................. �,, ,....Foundation ,� �_-_-- prop. line .., <br /> LEACHING LINE [ ] No. of Lines /............. Length of eoc i Tli e7_4*:O'�......... Total Length- ------------------ <br /> t 'D' Box ....._------ Type Filter Material/�l.l.�Depth Filter' Material_ �. <br /> _ ,r <br /> Distance to nearest: Well;12 '.:.: Foundation R....__ Property Line .lam ....a_. <br /> SEEPAGE PIT Depth Diameter .............' . Number .......... ......_.... Rock-Filled Yes ❑ No ❑� <br /> { ) <br /> ` Water. Table .Depth .Rock Size <br /> � 1111.111.1111-- --•-•-1.11---......--1111-• ................................ <br /> Distance to nearest: Well................................ ....Foundation ---------- ......... Prop. Line ............___.------ <br /> t REPAIR/ADDITION(Prev. Sanitation Permit96E ...-•-_-: Date .) <br /> x <br /> SepticTank (Specify Requirements) ....................... ....................:x, .ti::: _...........•......-----•----------...................-•--------------•------•-- <br /> Disposal Field (Specify Requirements) ---•-------- --------------------------------------I—...........................­ 1........---...------......... ......... <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. Horne owner or licen- <br /> sed agents signature certifies the following: <br /> j 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 becom ubject o orkm Compensation laws of California." <br /> ........................ .......... <br /> l Si'g'ned ned % Owner <br /> . <br /> By . _ ----------------------------1111-•-------------•• -------•.................................. Title.....:......... ............................. •••...... ............ <br /> (if other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ......:........ ...f.........................I............................ ................... DATE ----- <br /> BUILDINGPERMIT ISSUED -------------------------------------------•--=----•-•---- ..................................................DATE .::........... ...._....................... <br /> ADDITIONALCOMMENTS .....................................................•- ------------------------------.......................................................................... <br /> .. <br /> .................. ........ ...........•-_....... . •-•.....-•- .. .......--•-- .......... ......••................................................................._ <br /> ._... <br /> .--- ! <br /> Final inspection bY: . .r.._..... Date ..... .. . <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F- H- 13 241-'68 Rev. 5M / �' <br />