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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> Permit No. <br /> ............... ............-,.................... <br /> (Complete in Triplicate) <br /> -- .............. -- <br />'...-.....-...-... . . I-, <br /> Date Issued <br /> / This Permit Expires it Year From 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 `174 `-3•��•• •'��`'�"� CENSUS TRACT <br /> -. <br />' Owner's Name - .....................•---.,..._.-_...---..:........._.. Phone . �.. . .......; <br /> Address - .. ..-- ��s ...:..........................................:... <br /> ..... City <br /> •-•-.-.....---•--•-••--:-_-.-.License # ---- -: ••---•--..... Phone •:-............... ..:.:... <br /> Contractor's Name .�'''�' - •- � <br /> Installation will serve: Residence ❑Apartment House] Commercial:❑Trailer-GeW4 411 <br /> Motel ❑Other .---_ ...... .............................. - <br /> Number of living units:-..-t----- Number of bedrooms ............Garbage Grinder ............ Lot Size. 1 --••••••••-----= ........ <br /> Water Supply: Public System and name ______________________ Private. '] <br /> Character of soil to a depth of 3 feet: Sand 0 Silt[IClay [3Peat❑ Sandy Loam Clay Loam <br /> Hardpan ❑ Adobe ❑ Fill Material _..-...._.._ If yes,type ............................ <br /> f (Plot plan, showing size of lot, location of. system in relation to wells, buildings, etc. must be placed on.reverse side.) <br /> 3 NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,), <br /> PACKAGE TREATMENT [ SEPTIC TANK_ I ] <br /> Size .. ...... Liquid Depth .......................... <br /> Capacity <br /> .........TyPe . a ert .. <br /> ..Foundation ...................... Prop. Line ...................... <br /> i Distance to nearest: Well ......................... <br /> r <br /> LEACHING LINE No. of Lines - -..... Length of each line-------...__.- ------.-:---- Total Length ..........................:. %Y <br /> l <br /> D' Box Type Filter Material .......... <br /> ..........Depth Filter Material ------._-_..._._-...-•-------...........__.. <br /> E <br /> Distance to nearest: Well ........................ Foundation ................... .... Property Line •• <br /> SEEPAGE PIT [ ) Depth ..................:. Diameter •-- Number .---------......------------ Rock Filled. Yes ❑ •,-No <br /> ...............Rock Size <br /> Water Table Depth w. .:. ; .. <br /> Distance to nearest: Well .Foundation ... Prop. line __________..... <br /> C <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ............................................ Date ................................... <br /> ..--------•••------------- •----------- _-----_� - ----- <br /> t� <br /> Septic Tank (Specify Requirements) ---------------------------------------------- -•-•......... •- • <br /> ---•.. <br /> Disposal Field (Specify Requirements) .._._ _ _. __ <br /> t <br /> -----------------'-- ----­------------ <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 clone in accordance with San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District.•Home owner or licin. <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 _---------- ---------- y... - -......------•--.................... Owner <br /> ------------:....... .7itle ----• •-----------.---.........-----....-...-.......... ........ <br /> f other <br /> than owner] <br /> k FOR .DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY _ <br /> ................................................•---... DATE ./d.-/..C-"- -•-- <br /> BUILDING PERMIT ISSUED -_-----_---------- ••.... ---DATE ......:...:.....:..............••---....... <br /> ADDITiONAL COMMENTS .....-•-•............. , <br /> - ---•••----... ........... <br /> •..... ........ .-•----...........-......___-••.......-------•• <br /> Final Inspection b r�r Date/64.: ----- <br /> 4 <br /> p Y- ----_----- <br /> SAN_JOAQUIN AOCAL' HEALTH DISTRICT <br /> c u <br /> 13 24 1--An Qo.. 5AA 7/72 3 M <br />