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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> Permit No.. <br /> ---------------- <br /> --------------------------------------- <br /> ------- ---- <br /> (Complete in Triplicate <br /> --.-- Date Issued --- <br /> This Permit Expires 1 Year From Date Issued <br /> ----------------- --------------------- ----- <br /> Application is hereby made to the San Joaquin Local Health District for a per to construct and install the work herein <br /> described. This application is made in co�ml �nc�e with Co Ordinances No549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION -_;�rr�T�f_G.- ---------------------- - <br /> CENSUS TRACT ----------------------• <br /> -_-___-_- <br /> ---------Phone -------------------------------•---- <br /> Owner's Name <br /> ' ---------- - ---•----.. Cit /��IY�G�GA ----------- -----•----••-----•----••----•--.....-- <br /> Address ------- - ----- ------------- ----------------------------------------------- Y <br /> Contractor's Name ------�Z��-_�v_,lLc --------------------------------------------- <br /> ------ License # ��`?~a_��'- --- Phone -��-- --1-- ---------- <br /> Installation will serve: Residence WApartment House❑ Commercial ❑Trailer Court il] <br /> Motel ❑Other -------------------------------------------- <br /> Number of living units:------- <br /> /____ Number of bedrooms ___,3------Garbage Grinder ------------ Lot Size -------- <br /> --------•----------------- <br /> Water Supply: Public System and name ------------------------------ ------------------- <br /> Privatex <br /> Character of soil to a depth of.'3 feet: Sand'❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam Clay Loam;❑ <br /> Hardpan ❑ Adobe ❑ Fill Material ------------ If yes,type ____________________--___-_ <br /> I (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 /> I r � � <br /> PACKAGE TREATMENT [ I [ ] -- Liquid .Depth ------------------.-•-- Q <br /> SEPTIC TANK![ Size__'���._X_-��•�--5---------- c <br /> ------ No. Com ----Q-----•--- .. <br /> Capacity /�&P---------- Type ('�-Rcrc.15-'--- Material------------- Compartments <br /> k Distance to nearest-. Well ------------------------------------Foundation ---------------------- Prop. Line --____--____.:.--_---- <br /> LEACHING LINE [ ] No. of Lines �- J Length of each line------6A---------------- Total Length :-----�d� ----•-••-------• <br /> 'D' Box ---/--_--- Type Filter Material ijx'g_�---Depth Filter Material ----If---------------------------------- <br /> t Distance to nearest: Weil _____7 --______---- Foundation ...... <br /> Distance Property Line ----�--.-----.--- <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No <br /> i;'Water Table-Depth --- ---------------------------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well -----------------------------------------Foundation -------------------- Prop. Line -------..----------•- <br /> i <br /> REPAIR/ADDITION[.Prev. Sanitation Permit# ---------------------------------------------------- Date ------------- ) <br /> Septic Tank (Specify Requirements) -------------- ---------------- ----------------- ----------- <br /> t <br /> Disposal Field (Specify Requirements) --------_--- ------------------------------- <br /> V 1 <br /> --------------------------------- --------- - <br /> ------------------------------------------------ -- ---------------------------- ------------------------ <br /> ------------------------ <br /> •---------------------- <br /> -Draw existin an----- -------- -•-------- ---------- ------------- ---------------- - ----- ------ ----------------------------------- PP <br /> - - - ( g d 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 San Joaquin Local Health District. Home 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 -._ i_ t-- ---------- --------------------------------------------- Owner <br /> --------------------------------------------- -Title -------- - ----------- ------------------------------------------------ <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY . <br /> - �7 ---- ------------------------------ DATE �= '`� �`� ----------- <br /> APPLICATI-ON ACCEPTED BY -------!!c�-`-l-----`---- -------- -------=------------------- <br /> BUILDING PERMIT ISSUED -------------------- - --------------------------=--------- -------DATE -------------•---------------------------•.. <br /> ADDITIPNAL COMN4ENTS ------------------------- ---------------- <br /> ---------------------------------------------------------- <br /> = ------------------------------------- <br /> - ------------=----=-- <br /> -------------------'--------- ------------------- - <br /> -------------------- ---------------------------------------------Dated" /� <br /> Final Inspection b <br /> p Y: -----------•----- �`_" sem` <br /> ' SAN JOAQUIN LOCAL HEALTH DISTRICT �2 <br /> E. H. 9 1-'68 Rev. 5M <br />