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T FOR OFFICE USE: � - <br /> APPLICATION FOR SANITATION PERMIT <br /> .. .................... .......... 1..� <br /> f^ Permit No. . <br /> .......... .............................................. <br /> lContplete.in Triplicate=. . <br /> ...........:...............................I............. This Permit Expires ) Year From Date Issued <br /> Date Issued 15L <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 .. � � •... ...� i` F .� CENSUS T1tACT ........................... <br /> Owner's Name -----. �/ � !_ ._. --------•--••--- .. ? .... - .. ...Phone <br /> Address = 1 '` .~", C....�------------- -------------City .__ r .._.. :....... --------------- <br /> j; _ <br /> Contractor's Name : ___'_ .Q ---- --- ' .......................License # `, ��?---- Phone i � � �Al ----• l <br /> Installation will serve: ,�,,Resiclence Apartment House f] Commercial❑Trailer Couit ❑ � { <br /> ` N Motel ❑Other_ <br /> Number of living uni s:_.._.(-_..__�Numkier.of bedrooms .__ Garbage Grinder -......_...- Lot Size ....___ ..................................' � <br /> �" •--- <br /> Water Supply: Public System and nam® .Private <br /> Character of soil to a depth of 3 feet: Sand❑ Silt o Clay ❑ Peat❑ Sandy Loam fl Clay Loam <br /> Hardpan❑ Adobe Fill Material ............if yes,type..............• .,...___.... <br /> (Plot plan, showing size of"lot, location of system in relatloh to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if p'biic sewer is available within 200 feet,) �� J <br /> PACKAGE TREATMENT ( SEPTIC TANK ize...... ................ Liquid Liquid Depth <br /> .............. <br /> Capacity � �' -- - Type )- -�'_ -_-.----- Materials .:..No:~Compartments . :`....._._. <br /> Distance 'to nearest: Wel{ .........Foundation /.fir._........ Prop. Line <br /> -----�---------- Length of each line------ - --- •--=�_�__.._....._ <br /> LEACHING LINE No. of Lines -- --- g � -- -------Notal Length .12j2................ <br /> Box . .. Ty—Filter Material � x_.p=Filter Mated ---- .................................. <br /> Distance to nearest: Foundation ....f-..' . �....-...... Property Line .........:�:.... E <br /> MA <br /> £ �- <br /> SEEPAGE PIT .. Depth :..._..___. .Diameter __ �___.�__. Number ..._...� ..r........ Rock Filled Yes No <br /> [ � <br /> f <br /> Water Table Depth ............... :...........Rock Size C�.. �'-- - <br /> � ".' <br /> Distranfie .... - =---------_..... ._Foundation ..... Prop. Line nearest: Well t'-------- - -------------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit ` -- Date ....................... ) <br /> SepticTank (Specify Requirements) ..::. ..:................................-........................................ .:------•--------...---...........----..................... . . <br /> Disposal Field (Specify Requirements) ........... .....:..........:.:........:...... .. .................._..••---......-------•-•---• <br /> ...................................... ---•- ----------------............... ---•••-- •-_-•--------•-••-••---•---••-••••. ------ . . ------•--..... ....................... <br /> ------------------------------------------------------------------------------------- --------- - i..............----- . .......................-....................._._..... <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 clone in accordance with San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Healih.Distdct. Horse owner or licen- <br /> sed agents signature certifies the following: <br /> "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed ----- --------:.-- ----- Owner <br /> �f �,� --�� ------- <br /> BY � f -'�`-`---------•-------- ---------- Title f <br /> ri <br /> ( h t own-64, <br /> _ EOR DEPARTMENT USE. ONLY, <br /> APPLICATION ACCEPTED BY -/_ 4": - - .•--. . DATE- �' `7 �._ _....._... <br /> BUILDING PERMIT ISSUED ---------- -----------------------. .................... ..................... ..DATE ----------- ----._......___.. . ._ <br /> ADDITIONALCOMMENTS --------------_-- '•---- -•-------_-••--------- -------------- ---------------------------------------•----•-•--------•------- <br /> �/r..._. •--------- - - ------------------ ._...--•.. ............ ------I--------- •---- ----------- <br /> r..._. -----------•--- --•- --- ------. . -----•-------------------- ............................................ <br /> .. ..------ ----------------- •-- --••------------------------------ ­ <br /> ------------ --'----------------------- ...... <br /> Final Inspection by: ' <br /> ..,.--.. ................................................. ._..:..:.. ...Dot <br /> EH1-68 <br /> 3 -� S. N JOAQUIN LOCAL HEALTH DISTRICT 8/74. 3M <br />