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FOR OFFICE 115E: . <br /> APPLICATION FOR SANITATION PERMIT z <br /> o. <br /> (Complete in Tripiicatol Permit N <br /> sy _ - - _ . —F_ . ._. ---- <br /> .._.... Date Issued . �Z:.» <br /> This Permit Expires t Year From Data IssWd <br /> I'4 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 /> 1 <br /> JOB ADDRESS/LO CATIO >�'I�' .�'` - --. � ...CENSUS.TRACT ....... <br /> ,; .......................................,..... ......... <br />�E Owner's Name ........ . .:.. ..................... ..... .���..---........................,....................' ..Phone(J�...... ..................-....... <br /> Address -}"._.a1 .. .. .....City .. ............................... <br /> Contractor's Name �/?! _:-�G :. License # Phone <br /> Installation will serve: :I1 -Residence ErApariment House)[] Commercial❑Trailer Court <br /> Motel ❑Other:... .....................••........ <br /> Number of living units:..... (.-.. Number of bedrooms --::.Garbage Grinder lot Size } <br /> t Water Supply: Public System and name ........ ............................................ ...................................................Private <br /> Character of soil to a depth'of 3 feet: Sand:0 Silt E3 Cloy [3Peat[JSandy Loam❑ . Clay Loam [3 <br /> If Hardpan [� Adobe❑ Fill Material :...-......If yes,type ............... ............ <br /> IJ <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,) 57 <br /> PACKAGE TREATMENT SEPTIC TANK f Size. /V...IV ........ Liquid. Depth .Y....................%9 <br /> Capacity - T - "Material.. _... No. Compartments ........ ............94 <br /> Distance to nearest, Well 'gc' f .Foundation ...... ....... Prop. Line �....... <br /> LEACHING LINE [K]' No. of Lines _......2.............. Length of each .line....:.`-H................ Total length ..9A.................... , <br /> V'Box ..... Type Filter Material.:....4.K.......Depth .Filter Material .....j.q.................... <br /> Distance to nearest: Weil .._._._6.°..f......._ Foundation1D............ Property Line .�.... <br /> r Z............ Rock Filled Yes [� No Q;-' <br /> SEEPAGE PIT Depth -----. ..... . Diameter -__ ....... Number ....... ........ <br /> Water1 /l <br /> Table Depth ----- '-= f.�?.�..:..... --Rock Size __1_/ ...... .. .......... . <br /> Distance to nearest: Well ---------{--4?:k:.:--•.................Foundation ..... Prop. Line ...................... <br /> REPAIR/ADDITIONI;Prev. Sanitation Permit.........`.:..:-------- _ Date .................................. <br /> SepticTank (Specify Requirements) ...:...............................................................................•-...........................••........I..........,........ <br /> Disposal Field (Specify Requirements) ...._"__----:_ <br /> --•---------------•--•-•--------•------------ -------------........--••----------- ---------•---•...-----•------•---......................... - . ... - ........---- <br /> 1 -------------------------------------------- --•-----------..------------------_:.......•------------•---•,-_.............------------------.--...............------._.....................--•-........... <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that 1 hav� 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 Itlealth.Qistrld. Ham* owner or )icon• <br /> sed agents signature certifies the following: <br /> "I certify $bat in the performance of the work for which this permit Is Issued, I %hail not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> C. Signed ------------------------------- ---------- . ......_... Owner <br /> �� Title :... .. <br /> BY ;_. 5 i:.... .. �C U� <br /> (If other than,owner) <br /> FOR EPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ---- -----------•-------------------------------- ................ DATE <br /> BUILDINGPERMIT ISSUED''---..-: .....:...... ... .......... ......................-------------...-..................DATE ..._.._.,....__.._...............--- <br /> ' ADDITIONAL COMMENTS '...................:.....................•--...--•........---...---- •-----....------.._....__.._...----------•--- ---....--------:..._....._:---------------- <br /> �, <br /> ------ -----------------------•---------- -- --- ----•----------------...--------------------...._... <br /> �" --------- -- ---------- <br /> Final Inspection b ..... ..... ..:...Date ... ..�. lJ <br /> P Y ----------- -- ------•------._... - <br /> EH 13 24 1-68 Rev.` 5�t SAN J UIN LOCAL HEALTH DISTRICT 8/7& 3M <br />