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r i qp OFFICE USE: ; <br /> APPLICATION FOR SANITATION PERMIT ' <br /> r. Permit No. ... <br /> (Complete In Triplicate) <br /> .... This Permit Expires I Year From Date Issued 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 compli nce with County Ordinance No. 549 and existing Rules and Regulations. <br /> JOB A©DRESS/LOCATIO .f. .. .. .--_ .... ......... .....I``1.... ...C>rPISUS TRACY ......... <br /> Owner's Name ........... <br /> �------ ...........I......- --T................ ....................Phone . ._ .��---... <br /> Address ..............1 (�./._.... ------. -----...---..........................City .... ........ <br /> ]� '.. -- Phone ..YA4 'y�Q <br /> Contractor's Name ---------------I..-•------•- -----------�_.S cI�7..................•-----.License �#��. ----- -- --- <br /> installation will serve: Residencel,Apartment House f] Commercial oTraller Court <br /> / Motet Q Qther........................................... <br /> Number of living units:_....-[__--- Number of bedrooms --..•...Garbage Grinder ............ Lot Size _•/0.............. -. ................ <br /> Water Supply: Public System and name ................................................-.......—-------...........................................PrlvateX <br /> Character of soil to a depth of 3 feet: Sand tj Silt❑ Clay ❑ Peat❑ Sandy Loam P� Clay Loam <br /> Hardpan 0 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.) O <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT I ] SEPTIC TANK M Size.... . .. <br /> Liquid Depth .........�1�............. <br /> Capacity Type _.L� .---- Material..' <br /> No. Compartments .......... <br /> Distance to nearest: Well ........ <br /> 4-0— -...lo...-------.. Prop. Line .--s--........... <br /> l � <br /> LEACHING LINE No. of Lines ---••. ................. Length ofnneach line_...... 8__......-----. Total Length .. ..!?- <br /> V <br /> 'D' Box ...____._... Type Filter Material .l4. 7,.-L-----Depth Filter Material ......./1 4......................... <br /> Distance to nearest, Well ----S©--........... Foundation `...... Property Line --S .............. <br /> SEEPAGE PIT [ ] Depth --------------- .... Diameter ................ Number ............................ Rock Filled Yes ❑ No {] <br /> Water Table Depth .......... .....................................Rock Size --............. ................ <br /> Distance to nearest: Well ........................................Foundation ......-..-.......... Prop. Line ...................... <br /> REPAIR/ADDITION lPrev. Sanitation Permit# --------------------------- -------- ........ Date .......................I.......... <br /> ) <br /> Septic Tank (Specify Requirements) .... ......--------•--•.._.......--•--•..................•----...... ------------.................... ........-----•............. <br /> Disposal Field {Specify Requirements) .........-------------•--•-.....---•-••.... ..................... -•-----------•-••-- ........................ --------------- <br /> Y <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that l 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 llcen- <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 .. - <br /> -------------- Owner �'� <br /> BY ----- <br /> -------•------ ---------- Title ---....--- � L1.._�..... <br /> ( othe han owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ---- ...... . ........ -------------------•------------•-------• -- I...... DATE ..... .. <br /> BUILDING PERMIT ISSUED ._-__-- _-•-- - <br /> ------------ .-_-- DATE ------- -..._ <br /> .............................. <br /> ADDITIONAL COMMENTS ...r,.. , <br /> ..._ <br /> -------------- -- �s� <br /> ------------ <br /> ...--•-•-----------•--••--------------------- •- ...................... <br /> ------------------------------------- ----- <br /> Final Inspection by: ------------------C--7-a......---•-......--------••••......----•... ....................._..------.Date ......- . C> -3-7-6..... ... <br /> 13 22a J-6f3 fey• SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M <br />