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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ------------------------- -------------����-3- ----- Permit No. /" <br /> (Complete in Triplicate) <br /> ------------------------- ----- ------------------------- This Permit Expires 1 Year From Date Issued <br /> Date Issued -----------------_- <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/LOCATION .._..__46c?-L------ - -----'-------------------:----CENSUS TRACT ----------------------_--- <br /> Owner's Name ------ —---------------------- ---------------m------------------Phone .----------------------------------- <br /> Address -----')- i5e----------- City ------------------ _ <br /> Contractor's Name _-- -- .�-_/fir ------------------------------License #/,4:,5_5?--?9--'7—Phone ��.r24&'fZP <br /> Installation will serve: Residence rNd Apartment House❑ Commercial ❑Trailer Court l❑ <br /> €Motel ❑ Other ----------------- 7-- --- -- --------------- <br /> Number of living units:.-./---_ Number of bedrooms ---�__Garbage Grinder./- _ __ Lot Size <br /> System � <br /> t/� vr � Yo *_ �-1�-�___--.-.--- <br /> WaterSuPPIY- Public and name ._�- ---�'��� -�---�------•------•---------Private } <br /> ❑ <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ + <br /> r- Hardpan ❑ Adobeill Material -- .---.---- If yes,type --------- --------------- <br /> (Plot plan, showing size <br /> It lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) I <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewerisavailable witkin 200 feet,),. <br /> PACKAGE TREATMENT f ] -'SEPTIC TANK'f ] Size----------------------------- �.- -- - Liquid-Depth-------` -------- \ <br /> Capacity --- ----- Type -------------------- Material---------- ---------- No. Compartments -----------------:. <br /> Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line---------------- <br /> :•___-- <br /> LEACHING LINE [ No. of Lines ----------------------.- Length of each line---------------------------- Total Length ____�_____ ' <br /> ; r. <br /> 'D' Box ___.__ ---- Type Filter Material ____________________Depth Filter Material --------------------._____.__._.__..'____ <br /> Distance to nearest: Well ------------------------ Foundation __.-------..__:-------._ Property Line _ -_-----.------ <br /> SEEPAGE PIT [ ] Depth __ ----_------------ Diameter ---------------- Number'_``---- ----------------- Rock Filled Yes (] No 0 <br /> r., F <br /> Water Table Depth - -- -- ------------>------.-Rock Size.------ = -- --------------- <br /> Distance to nearest: Well ----------------------------------------Foundation -----------;--;_w-- Prop. Line -------------------- <br /> t <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ------ -------------- ------ Date ---------___-_,_____--__--___-_-_} <br /> Septic Tank (Specify Requirements) ----------------------- -- ----------------------- - -------------------------- <br /> n' <br /> ------------------------- <br /> i i <br /> Disposal Fier d (Specify Requirements) -__a_- _GF---_____ __�-.__ �-� � ___�__,r__��------- � <br /> - . <br /> '�� - -- -- -- - ` - ----- -------------- ------------------------ <br /> ------------------------------------------------------- -------------------------------- --- ------ ------ ------------------------- ----r-------------------------------------- ----- <br /> (Draw existing and required addition on reverse side) <br /> n <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with Son Joaquin <br /> County Ordinances, State laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or liven- h <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 sum <br /> ch anner <br /> as to become subject to Workman's Comp sati.on laws of California.", i <br /> Signed _ ---- -- --------------------------- <br /> -- ----------------- =------------- Owner ° <br /> BY -------------------------- - --------- - --- ----------------=------------- Title ---- ,/ � --- ---- ------------- <br /> (If r than owner] <br /> s <br /> FOR DEPAiTMENT USE ONLY f <br /> APPLICATION ACCEPTED BY ---------- ----� - --------------------------------------------- DATE -7.`.... <br /> BUILDING PERMIT ISSUED ------------------------------- ------- DATE ------------------------------------------ <br /> ADDITIONAL COMMENTS ------ -------------------------------- -------- ----- ----- <br /> -- --- <br /> ----------- -- --- ----------------------- ------------------- --------------------- ----------------------. - - ---- ---- <br /> ----- --- --------------------------- <br /> --------------------------- ------------------ - - - ----- - ------ - ------------------------------------------------------------------------------------------------------------------------- <br /> - --- -- -- -- - ------ - --------------------------- ---------------------------- ----------------------------- <br /> Final Inspection bY: = r Date -- " <br /> n AQUIN LOCAL HEALTH DISTRICT t <br /> E. H. 9 1-'8_Rev.'51V1� <br />