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EOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ••-••--��••--�----•- Permit No. <br /> 1Complete in Triplicate} <br /> ....................................................... -- . . , Date f slued . //9 7 S - <br /> .............................................. This Permit Expires t 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 herein <br /> described. This application i49i <br /> plionce with my Ordinance No 49 and existing Rules and Regulations: <br /> 106 ADDilfSS/LOC N ..... . .. . . <br /> , .......�..�.... ....................CENSUS TRACT —............................ <br /> Owner's Name ._. .......... .. . _.--•.....................:. . ............Phone .......................... --- <br /> City -1........... .. . . ....... .... ................Address ....... . _ . .. t'I <br /> Contractor's Name ........ ............ --- .__._ . ,. . . -. License.f�ylap�.� Phone . .. ` <br /> --- <br /> Installation will serve: Residence Apartment House 17 Commercial QTraller Court i <br /> Motel ❑Other.....---•-•......•----•--•.................. r <br /> Number of .living units:............ Number of bedrooms Garbage Grinder Lot Size JRZ. ..X• .. <br /> Water Supply: Public System and name - --------------------•--•--........................_..._....................................................Private ® =' <br /> Character of soil to a depth of 3 feet: Sand b Silt Q Clay 0 Peat.Q Sandy Loam Q Clay Loam �[ <br /> Hardpan Q Adobe 0 Fill Material ......... If yes,type ..... . ............ � <br /> i <br /> {Plot plan, showing size of lot, location of system In relation to wells, buildings, etc. must be placed an reverse side.l <br /> NEW INSTALLATION: (No septic tank or seepage pit.permitted If public sewer is available within 200 feet,) � <br /> PACKAGE TREATMENT [ ] SEPTIC TANK I ] Size... . . .. . Liquid De th <br /> -- . 6. ............... P ....#.......... ...r <br /> Capacity - ...... Type r ....,... Material...................... No. Compartments . ."Z2........... .G <br /> Distance.to nearest: Well ......4._0.......................Foundation ............ Prop. Line ..3.61...:.... <br /> LEACHING LINE [ ]. No. of Lines ...-_ ...-.--- Length of each line.... Ir,4 ............. Total Length 1.743._...........f <br /> Type Filter Material Depth .Filter Material . <br /> 'D' Bax - ---- •,�•r <br /> Distance to nearest; Well -. Founddtian ._..._... Property Line ....................... <br /> ................ --....._.....-- <br /> SEEPAGE PIT [ J Depth . ... ... 1.- .,�lameter Number .. .................. Rack Filled Yes No <br /> Water Table Depth -----------------------------••---- ............Rock Size ................................ <br /> Distance to nearest: Well ........................................Foundation .................... Prop. Line <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 /> 1 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;Dlstrict. Home owner or licen- <br /> sed agents signature certifies the following: <br /> "l certify that in the performance of the work for which this permit Is issued, l 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 ..._...--- - -- -- -------------------- ,, itle . -•....... .................:--........................... <br /> (IA-.l'hr t <br /> Aer} <br /> FOR WPARTMENT USEANLY <br /> APPLICATION ACCEPTED BY ----- <br /> .... .................................................................... ...... ................... DATE <br /> BUILDING PERMIT ISSUED ............................ ...._ ......DATE ..................................I......... <br /> ADDITIONAL COMMENTS .. --....--•- ... <br /> ----- .................................................................. . ............................................. ........................................... <br /> Final Inspection by:.......... <br /> ... . ....... .. ............................. -•------------------ ................... ...Bate ...._'....._...... <br /> EH 13 2h `6v* SAN JOAQUIN CAL HEALTH DISTRICT 8/7h 3M <br />