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FOR OFFICE USE.- <br /> APPLICATION FOR SANITATION PERMIT _ <br /> .......................I.........---------......... Permit No. !:.�. ...!._`.../... <br /> .........................•-_.._..... <br /> iComplete in Triplicate) <br /> ....... This This Permit Expires 1 Year From Date Issued Date issued <br /> Application is hereby made to the San Joaquin Local Health District for a <br /> pp Y q permit to construct and install the work herein <br /> F. described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCAT ON ... .._. ..... If ......_.....CENSUS TRACT .------------- <br /> :. <br /> I Owner's Name ..... -_ ......... Phone ... "i <br /> Address ! <br /> :.>.. <br /> Contractor's Name i � ,,_, ._.;.License'# 12.& ., .Z#'hone <br /> Installation will serve: Residence W-Kpartment House 1-Commercial ❑Trailer Court; O I <br /> Motel n.Other .:.. 5y....-.::.._; .. <br /> Number of living units:._,;., .,.,, Number of; bedrooms ..;�?�_Garboge Grinder ..... Lot Size ....... ....... <br /> Water Supply: Public System and name .._. ----------- -_ p :.._...........:.... ........Private.. <br /> Character of soil to a depth of 3 feet: ;Sand iit❑ Clay 0' Peat 0 Sandy Loom ❑ Cloy Loom ❑ <br /> Hardpan Adobe [] Fill Material _ If yes,:type ... ... ...... . ... : . <br /> (Plot plan, showing size.of lot,,location of system°. in..relation..to.wells',,bualdiri'gs, _etc smust -be .ploced on reverse side:) <br /> } <br /> NEW INSTALLATION: F <br /> (No septic 'tank or seepage,pit permitted if vblic sewer:is ovollable:within,200 feet,)' i <br /> PACKAGE f I <br /> TREATMENT [ ]. SEPTIC TANK I ) Size.'.{. 7,?C_ '. Liquid depth ..`� .:..:...:.......i. <br /> Copaci ! <br /> ry� IVlaten o.; Compar#ments .._, .. _ <br /> r .11 <br /> EDistance to nearest: Well :_ , . Ste'__•--..;. ...Foundation . .1= r ... ... Prop. Line`_...�`"---l._.....).W <br /> LEACHING LINE No. of LinesLengthg , •. <br /> [ - ..�.... of-.each line ., _.... _ � <br /> �� r.....,... Total Length, .�_-...-•---•---._.._.�. u' <br /> i D` Box ( Type Filter;Material Z, Depth `Filter Material :_ ' _ <br /> :, [ rt <br /> d <br /> Distance to nearest: Well ._ ... 6'.- -_- .,.Foundation L. 7-- "-'.. Property Line <br /> T <br /> SEEPAGE PI `[ Depth :-- - Diame'ter _.. : Numbers_: -_-•.;. <br /> I <br /> . . Rock Filled Yes No .0 <br /> Water. ;Table Depth,',-......... :.. .D_�._. Rock 5i ±� <br /> -. 6 y ... Prop. Line of <br /> # : Distance to,nearest. Well .._:.__. �-� .,.,Foundation >' _Q <br /> REPAIR/ADDITION IPrev. Sanitation Permit# _._ _:...._ ........... ..... Date <br /> . ,.... -. ------------- <br /> 'Septic Tank (Specify,Requirements) _ .;.--.--:__.... ...... - ------------- i <br /> Disposal Field (Specify Requirements) =------------------­- ----- -- ----- --- -------- ...... . ...._.-_..... <br /> l <br /> ----------- ----............ .... ------------------ -------------------- ........ .............'----._ ....... ....... <br /> ....... ................. .......... <br /> ......._..-...............___...--------- .._... <br /> ..__.._.___.... ..__....... <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 Rule`s and Regulations of the San Joaquin Local Health District. Home owner or iicen. <br /> 4 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 ✓lam' ...._.. . Title . . : <br /> v: ......:................... <br /> (If othe on owner) <br /> FOR EPARTMENT USE ONLY• <br /> APPLICATION ACCEPTED BY ...... _. -�.. .. <br /> . <br /> . <br /> . <br /> . <br /> . <br /> . _._ DATE :_�.C�.1..�.---�.�..................' <br /> _...... .. .... <br /> BUILDING PERMIT ISSUED ......... ....:......:. ..... - -- ..._..-DATE ............... .................... <br /> ADDITIONAL COMMENTS ......... _........ ......:....' <br /> - .............................................. <br /> -- <br /> /f� i / <br /> Final inspection by: .._.. '..------ ------------------------ ---:..Date . J.�9_!�........... ............... <br /> _. * . L HEALTH, DISTRICT <br />, A. ,.OAQUIN LOCA.... .. _ _.... � .. <br /> F H 13 24 t.-1,A Qe.. rAA - 3') 'A u <br />