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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br />' .........................................I..--•---•--••-.. Permit No. <br /> (Complete In Triplicate) <br /> ....................................... <br /> Date Issued <br /> .........._ _Phis Permit Expire` ] Year From Date Issued <br /> Application is her 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 /> / f .. <br /> JOB ADDRESS/LOCATION ....I7�, ..._-. .._-. ,,/ J.�:! •........................CENSUS TRACT ��' . <br /> -.-Ph7n <br /> � -p <br /> �­�­.-.?;."­Owner's Name <br /> Address ......d/-� __ ........... city <br /> .:.._..... <br /> Contractor's Name .......License # � Phone <br /> r <br /> .�.-•---..,.��.._... <br /> Installation will serve: Residence BAportment House f] Commercial ❑Trailer Court 0 <br /> Motel ❑Other _.-.................................... <br /> ...._ <br /> Number of living units:---•_.... Number of bec)rooirls Garbage Grinder 'Lot Size• �« <br /> Water Supply: Public System and name ...............r i .. � �..... ....... - -ET <br /> .... .. ..........: ............................. Private <br /> Character of soil to a depth of 3 feet: Sand 0 Silt❑ Clay [], Peat❑ Sandy Loam 0 Clay Loam <br /> `Har'dpon p Adobe 0 ..Fill Maieflol ..... lfuyes,type........................... <br /> (plot pian, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) J <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,] <br /> PACKAGE TREATMENT [ ] SEPTIC TANK ] �_ Size....................................A -_--:..•_.. Liquid Depth .......................... Vi <br /> Capacity -------- ... Type -----------------_ Material-:.......... No. Compartments ....................... <br /> Distance to nearest: Well --------------------------------------Focinclation ...................... Prop. Line ...................... <br /> LEACHING LINE [ ] No. of Lines- _...,.__._`.._.._ ___ Length of-each rlane�:: _:...r.__ .__"___ Total Length ............................ <br /> r -- a w <br /> 'D;-Boz............ Type Filter Material ................Depth Filter Material ........... ................................ <br /> f ... <br /> Distance to nearest: Well .............___.... Foundation ..............1_:•._... <br /> . . Properly Line ........................ <br /> SEEPAGE PIT [ ] Depth _____________ Diameter ...... Number :...'___ ........... Rock Filled Yes ❑ No 0 <br /> i Water Table Depth�V: --:. y 4..Rock Size .----.....-•--._........ <br /> ---- •-• <br /> �-L3istance to nearest: Well ------------ ........ ---- -- <br /> _�Prop <br /> REPAIR/ADDITION(Prev. Sanitation Permit;# ............. ------------------------ Date ....•.... ...............) <br /> Septic Tank (Specify Requirements) ----•-.._. ....... . ---_--. .................... ........_....... <br /> 69 -J <br /> Disposal Field ISpecify,t Requirements]s �-- <br /> -. <br /> ................... --------------------------------------- ........... -----------------------=------------__...---------------•-•----.-_..........----------------,..------...._..............•--•- <br /> !Draw exi`sfina pnd.required addition on reverse slde) -r . <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. Hattie owner or Iicen- <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 orkma 's Compensation laws of California." <br /> Signed -------- ----- -- . -----••-------------------------- --.._.. ----- Owner <br /> Title - �.. ... - ------0 <br /> other tha owner) <br /> FOR DEPARMENT USE ONLY <br /> APPLICATION ACCEPTED BY _ ._-... --... ------------ ------------------ DATE . <br /> BUILDING PERMIT ISSUED ----------------------------------------- <br /> .................._...--•----•- ----- .....DATE ..........------ <br /> ADDITIONALCOMMENTS ----------•-- ••............................. -----------•----.----------..------- -------------------------_ -...-------------...---....----...-.. <br /> ---------------------------• --•-----------.---------...................._.--.-----------------------............... --------------- ------------------------- ------- <br /> --- ----- <br /> - . <br /> Final Inspection b Dote .. .......................- ---. <br /> --- ----------------- ---- <br /> EH 13 2L 1-68 Rev. SAN JOAQUI LOCAL HEALTH DISTRICT 874 3M <br />