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`ICE USE. <br /> FOR Of+ APPLICATION FOR SANITATION PERMIT <br /> ............................ . ...... <br /> .. . <br /> lComplete In Triplitafel Permit No. .. <br /> ........... ........ . <br /> This Permit Expires I Year from Doti Issued....... .......Dole Issued 7— <br />................ ......... ........ ........I <br /> Application is hereby,made to the Son Joaquin Local Health District for a permit <br /> mit to construct and Install the work herein <br /> described. this application is made In compliance County Ordinance No.. 549 and existing Rules and Regulations: <br /> JOB ADDRIESS/LOCATION ..........................CENSUS TRACT ........................... <br /> Owner's Name .. <br /> ............................. ...............Phone ......... ....... ....... <br /> . ...... .. ..... <br /> Addresscity ............. ................. .......... <br /> 7 <br /> Phone .............................. <br /> .............License # ........... <br /> Contractor's Name .. . ... . .... <br /> Installation will serve: Residence Apartment H"a Commercial OTrallor Court 0 <br /> Motel 0 Other .... .......... <br /> Number of living units--.,.......... Number of bedrooms .... . ....Garbo ge Grinder ............ Lot Size ... ......... <br /> Water Supply. Public System and name .... .........I............................................................................................Private <br /> Character of soil to a depth of 3 feet: Sand 0//lilt 0 Clay 0 Peat[3 --Sandy-Loom:-(3--Clay Loom [3 <br /> I Hardpan(Ef Adobe 0 Fill Waterial ......:..... If yes,type................ ............ <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildingi','-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 /> PACKAGE TREATMENT [ ] SEPTIC TANK Size.......................... ............I........ Liquid Depth ........................... <br /> Capacity ........ .... Type .................... Material.............__....... No. Compartments ......I............... <br /> Distance to, <br /> nea<re,.st: Well .-........ ............*.............Foundation ........................ Prop. Line ...................... <br /> %Y <br /> LEACHING LINE No. of Lines --------------- ------ Length of each line....._ ._. .......... Total Length .......... ......I......... <br /> V Box .........:,.,.,.Tyoe Filter Material ....................Depth Filter Material .....I..................­ ................. <br /> Distance to nearest: Well ......................... Foundation ........................ Property Line ......... .............. <br /> SEEPAGE PIT j I Depth ............... .... Diameter. ................. Number ... ........_........ Rock Filled Yes No (P. <br /> Water Table Depth ........................­­.......... .........Rock Size•...:............................ <br /> Distance to nearest- Well ------_----_--":.:.......:.......Foundation .................... Prop. Line ...................... <br /> REPAIR/ADDITION(Prov. Sanitation Permit a# <br /> ermit# ........ .......... ..... ....... Date ...-----...............,..._......I <br /> Septic Tank (Specify .Requirements)........... .... ..... . .................. ................. <br /> ,........................ <br /> .......... ..... <br /> Disposal Field (Specify Requirements) _1& --- <br /> ............ ... ...... .................. ....................................................... <br /> ...j ......... - - ----- ..... .. _------ <br /> ..................................................................... .................. ........ ................ .............. .................... ................. ........ ............ .......... <br /> lDraw existing and required adclition,on reverse side) <br /> I hereby certify that I have prepared this application and that the Work *111 be don* In accordance with San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health-District.-Home aw or of 11cen- <br /> sod agents signature certifies the following: <br /> "I certify that In the performance of the work for which <br /> thIs permit Is Issued, I shall not employ any person In such manner <br /> as to become sub t to Workman's Compensation laws of California." <br /> Signed .... <br /> ----- --- Owner <br /> By .--6 .... . ---- <br /> .............. .................... <br /> ------------ title <br /> If other than owner) <br /> FOR IDEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED By Y............ ............. . ............................... DATE <br /> --------- ----- <br /> " <br /> Ld <br /> ........... . "' <br /> BUILDING PERMIT ISSUED __-_............................ ........................................... ............D'ATE .... - <br /> ...--.--..------- <br /> ADDITIONALCOMMENTS ---------------------------••-----..._...-"----....--""- ------------------------------ .............. ........................................ <br /> ------------ ------­----------------- --------------------------------------------------------------------m-----------------------------------­...................................­......... .......... <br /> --------------------------------------&-----------------------:.......w-----------------------1......................... ...... ....................... <br /> --------------------------------------------------------- --___ ------ - ------------ ----------------------------------------*------------- ................... <br /> Finol Inspection by: ...........................a a�A-- - ---------------­---I.................-----........--------._.......Date <br /> ............ <br /> EH 13.2h 1-68 Rev. 5M SAN AQUIN LOCAL HEALTH DISTRICT 8/7h 3M <br />