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FOR OFFICE USE: II <br /> --------------------------=------------------------ APPLICATION FOR SANITATION PERMIT <br /> ` (Complete in Triplicate) Permit No. --7t7- <br /> ---------- <br /> _73— <br /> --- it X This Permit Expires 1 Year From Date Issued Date Issued _ __- 'a�.� <br /> � <br /> I! <br /> Application is hereby made to the San Joaquin Local Health Districtfor a permit to construct and install the work herein <br /> described. This application is made in compliance with ounty rdinance No. 549 and existing Rules and Regulations: <br /> li <br /> JOB ADDRESS CAT N .---- _1 /- ------ / - �'�-� —------ <br /> CENSUS TRACT S` .I <br /> Owner's Name --- --------Phone --------------------------------- <br /> --- - =- ----- - --- - --- <br /> ----------- <br /> Address '�` 1 /- 1/__ lam_ ------- `' City -----------�.�. <br /> Contractor's Name ,___ _ m� __ ._____ =_.License# --LP-3_FyPhone ______________________________ <br /> Installation will serve: jl Residence ]Apartment House❑ Commercial [:]Trailer Court i❑ <br /> Motel F!Other ------------------------------------- ----- <br /> Number of living units:---.------- Number of bedrooms ___Y--Garbage Grinder ------------ Lot Size ----------------------------____, <br /> Water Supply: Public System and name ---------------------------------------------- -------- --------- ---------- ---------------------------------Private <br /> Character of soil to a depth of3 feet: Sand'o Silt❑ Clay ❑ Peat ❑ Sandy Loam .[J/ Clay Loam <br /> Ij I Hardpan ❑ Adobe-E-] Fill Material ------------ If yes, type ---------------------------- <br /> (Plot plan, showing sizel!of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) � <br /> NEW INSTALLATION: (No septic tank or seepd`ge.pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT <br /> [4] SEPTIC TANK'{ j Sized-- ---------------- ------- -------- Liquid Depth --------------------------- <br /> ,i � <br /> f <br /> Capacity ---------------- Type -------------------- Material;--------------------- No. Compartments ------ ------- :.... <br /> Distance to nearest: Well --------------------------------------Foundation ---------------------- Prop. Line ---.----------- ------ <br /> t q <br /> LEACHING LINE [ ] No. of Lines ------------------------ Length of each line- ---------------------- Total Length ------------________________ <br /> 0 <br /> 'D' Box ------------ Type Filter Material --------------------Depth Filter Material -----------------------------...-...... <br /> ._--- <br /> Distance to nearest: Well ---------------------------Foundation ____.___:______.____ Property Line ------------- <br /> SEEPAGE PITI. I I Depth -------------------- Diameter ----________ '_.Number ____________________________ Rock Filled Yes No <br /> �i , <br /> F Water Table Depth ------------------------------------------------Rock Size ---Y---±-"L-------------------- <br /> t. Distance to nearest: Well ________________________________ _ _Foundation ________ ---------- Prop. Line ___________.._...._... <br /> C <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------11 <br /> Septic Tank (Specify Requirements) ---------------------------- ------------------------------------------------- ----------=---------- <br /> p_sal Field (Specify Requirements) ------ ---------------- 4 <br /> rr <br /> ---------- <br /> - - ---- - -- - - - <br /> �J -------------- <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 done in accordance with Sari .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 manner <br /> as to become:subject to Workman's Compensation laws of California." <br /> Signed -----------'------------------ `--------------- <br /> � Owner <br /> B ii / t ------ �O "--------- <br /> Y ------------ - �� U Title <br /> '(If other than owner) <br /> II OR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED]BY --- ---------------------------------------- --------------- DATE . ` � --------------- <br /> BUILDING PERMIT ISSUED -------------------------- -------------------------------DATE -------------•--------------------------- <br /> ADDITIONAL COMMENTS ---------- - - ------------------------------------- <br /> 4 ----------------------------------------------------------------------------------------------- - -- <br /> ----------------------------------------------- ---------------------------- ----------------------------------------I----------------------------------------------------------------------------------- <br /> ii <br /> --------------------------------- -------------------------------------------------------------------------------------------------------------------------------------------- ----------- <br /> --------------------------------- ii ----- -- -- <br /> Final Inspection b '� <br /> p Y� - I -�-� --;-- -------------------------------------------- ---- ------------- -- Date �y'._.---`-�..----��-------------------- <br /> iSAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'6B Rev. 5M <br />