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FOR OFFICE USE: j <br /> APPLICATION FOR SANITATION PERMIT .. <br /> ......................1................... Permit No. 2s.n... T <br /> SComplete in Triplicate) <br /> . ... .. ..... . <br /> .......................................... <br /> . Date issued <br /> i.._-._•.................... This Permit Expires 1 Year From bate 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. 5.49 and existing Rules and Regulations. <br /> o A/ _ <br /> JOB ADDRESS/LOCATION -rQ= ..-- .-_ ...................... CENSUS TRACT ......- ........... <br /> Owner's Name .// .. . ....:... ..-'...,.............. ..............Phone .------......................:. <br /> \� � <br /> ...IAddress -...�a�.�.t------------------•-••--------•--.-..--...... --------•-- ........... city ---..._.-. ..-qq ........................__..---........................ <br /> Contractor's Name teq �:•:.License # Phone ...... <br /> Installation will serve: Residence (Apartment Houseo Commercial:❑Trailer Court 0 <br /> Motel ❑Other -------------------------- ----------------- <br /> Number of living units:.../....... Number of bedrooms .3------Garbage Grinder .... ....... Lot Size ................---------.: ----_.-____. <br /> Water Supply: Public System and name ---------------------------- ---------------- _.------------------------I........ ........._..........Private <br /> Character of soil to a depth of 3 feet: Sand 0 Silt E] -Clay ❑ Peat❑ Sandy Loam Q Clay loam <br /> Hardpan ❑ Adobe'❑ Fill Material ------------ If yes,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 avoilable within 200 feet,) <br /> PACKAGE TREATMENT SEPTIC TAMC[ ] Size............ ............................ ...... Liquid Depth .......................... <br /> No. Compartments � J <br /> Capacity .................... Type ----...__. ......... Material...................... .........._......:...-t1 <br /> Distance to nearest: Well ....................................Foundation ...................... Prop. Line ......................It7 <br /> LEACHING LINE [ ] No. of Lines ------------------------ Length of each line------------------.......... Total Length ...................... <br /> 'D' Box ...... Type Filter Material .....:..............Depth Filter Material .............---------------.-----..-------- <br /> Distance to nearest: Well .......::............... Foundation ....r. Property Line ....__._... ............ <br /> SEEPAGE PIT ( ] Depth ...............:.... Diameter ... ............ Number..................:....:----- Rock-Filled Yes ❑ No 09 <br /> Water Table Depth -------- .......................................Rock Size ........................... 17 <br /> Distance to nearest: Well ................................:......Foundation -------------------- Prop. Line ............... -� <br /> REPAIR/ADDITION(Prev. Sanitation Permit# --------------------------------------------- Date .........................-........ <br /> I <br /> Septic Tank (Specify Requirements) -------------- ------ - <br /> -.. .......... .... ..............................• ------------ <br /> _.------ -------- <br /> Disposal Field Specify Requirements) ..GL --* - -•-• .... -- ------ <br /> , :. --------- ---------- --------------..1..... ------- - -- <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 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, I shall not employ any person in such manneir <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed .... ------------------------------ ............. Owner <br /> By ................ K .. <br /> Title .. - <br /> (If other than owner) <br /> - F <br /> OR DEPARTMENT USE ONLY <br /> , ------•.....................•----------• . <br /> DATE .:rZ ...---.. <br /> APPLICATION ACCEPTED BY ..._.. <br /> BUILDINGPERMIT ISSUED .................:....•--......-----•--•---......---..:.....___._.......:.........----••--•- .........DA _..--... ................................. <br /> ADDITIONALCOMMENTS .... ................................................................. ..._...............------...._...-................------7............................ <br /> ....................................................................... ....... ............ ----..I---........--•• ...... <br /> .. <br /> ........................................ ~_....p :..----.--------•--.----- --.-- --.....-•---..........--------.....- --•• r•� _ .:... ...._. <br /> Final inspection by: -- <br /> .e.... ........---•.Date i!.:.e <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> c u 13 241-,AA Rov SAA 7/72 3 M <br />