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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMITS_ <br /> (Complete In Triplicate) <br /> Permit Na. ..................... <br /> ....... <br /> ..................................•-- ........... . <br /> Date IssUed ./-.2..... <br /> This Permit Expires I Year From Date Issued . ...... <br /> ............. ........ ............................ <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and Install the work heroin <br /> described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations- <br /> - <br /> JOB ADDRESS/LOCATION .........CENSUS TRACT .................... <br /> Owner's Name ....... ....................Phone ............._...................... <br /> .. . ..... <br /> Address .......... --- ---•-------r..__ .. city ....................... ...... .................... <br /> one <br /> I Se # <br /> Contractor's Name License Ph <br /> Installation will serve: Residence 0 part Commercial[]Trailer Court 0 <br /> Motel ❑Other ............................................ <br /> Number of living units:.... Number of bedrooms ..J.___.Garbqge Grinder ........... Lot Size .. .... .. <br /> Water Supply: Public System and name ......... .......... .............Private 0 <br /> ............ <br /> Character of soil to a depth of 3 feet: Sand Silt 0- Clay 0 Peat 0 Sandy Locim 0. Clay Loom IN <br /> Hardpan 0 Adobe 0 Fill Kotdrial .........__If yea,type................ ............ <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,) <br /> PACKAGE TREATMENT f SEPTIC TANK f Depth ....... <br /> Size ...........,Liquid ...... <br /> 04 <br /> Copcicity /..�kz_e�iype_404, aterial....4 -No. Compalornents ........... . <br /> Distance to nearest: Well ........Z0.0...............Foundation ...to......... Prop. Line ....i.�....... U1 <br /> LEACHING LINE No. of Lines ------------- Length of each line------7$............... Total Length .0............. <br /> D* Box ------ Type Filter Material Depth Filter Material .......... <br /> ............... <br /> Distance to nearest. Well ........... ............�Founclation -_------------ 'Property Line............... ....... <br /> SEEPAGE PIT j Depth Diameter C. Numbe'r ------ ... ......... Rock-Filled Yes No 0 <br /> N . 'A 0 <br /> Water Table Depth ........................ ------- ---........Rock Size ..... ................ <br /> Distance to nearest: Well ....................... ................foundation A........ Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitotion Permit# ............. -------------------- <br /> Date ..................................I <br /> SepticTank {Specify Requirements) -----I——......................... . .............................................. ._................•--.._..... -................. <br /> Disposal Field (Specify Requirements) ......................................................... <br /> ......................................... <br /> --­------­­---- ---------------------------------- ----------------­- ......... ----------­-------- ----------- ------------------------------- ................. ...................... <br /> ------------------I----------------------6--------------- .............. -----------------------------------....................................•.........................._••. ...................... <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 Son Joaquin Local Health-District. Home owner or Been- <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 to Workman's Compensation laws of California." <br /> Signed <br /> ....................... ---­----------- Owner <br /> By ------- <br /> -- --------- ........ .......... ............................ ------- <br /> a n <br /> FOR DEPARTMENT USE ONLY <br /> .12a...I-------------------- DATE ------------ ------- <br /> BUILDING PERMIT ISSUED --------- ­ zZ ------ <br /> APPLICATION ACCEPTED BY K�- <br /> ­ �--------------------------------------*-----------------------------------------DATE .... ........................ ------- <br /> ADDITIONAL COMMENTS ........................... .................................. <br /> ...........I——- <br /> ................. ----------------------------------- --------------------------------------I....... .............................................. ......... ........ ......... <br /> ­­­­----------- - - ----------- <br /> ......... .............. <br /> ------------------------------­ <br /> -----------I------­­­. ......... 7 <br /> Final Inspection by. .......... ------------Oat <br /> EH 13 24 1-68 <br /> . . ......... ----------- <br /> . ..... .. --- ...... <br /> --- -- ----- e <br /> 11ev N JOAQUIN LOCAL ALTH DISTRICT 8/74 3M <br />