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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT f <br /> Permit No. ....... ..... ••- <br /> (Complete in Triplicate) <br /> -...........-.............................. Date Issued .3 .I.V <br /> ..-....�_... .. ... <br /> ................ r <br /> This Permit Expires 'i Year From Date Issued <br /> Application is hereby made-t`6' the San Joaquin I-Seal .Health District for a permit to construct and install the work herein <br /> described. This application is made in compliance with Cou'nty;Ordina ` No. 549 and`e�fisting Rules and Regulations: <br /> JOBfi� ......... r CENSUS TRACT ..............::........... <br /> �.._ . <br /> Phone .............. <br /> Owner's Nome - ................................. ..__..: <br /> Address :-..s9a._.�-1:�. - City .......---------------_-�?�................................. <br /> License #,2_1�:..`�.. -. -_ Phone L -• <br /> Contractor's Nome .. � r -Q ��1-- , <br /> Installation will serve: Residence Apartment House] Commercia`i`[3Trailer Court C] <br /> Motel-[:].Other ------------.......................... <br /> Number of living units:..../-_- Number of bedrooms ..Z...Garbage Grinder /.tfW..- Lot Size ..- .. <br /> r�ci-� ..:............... <br /> WaterSupply: Public System and name ..........................................................-- '= --------------•--....-•------- ---_-------•.Private, <br /> W ) <br /> Character of soil to a depth of 3 feet: Sand ❑ Silt❑ Clay 0 Peat�'�. Sandy Loam 0 Clay Loam ❑ <br /> Hardpan Adobe ❑ Fill Material ............ if yes,type ---------_ -------------- <br /> (Piot plain, showing size of lot, locatlon.-of._rsystem in-relation for wells, buildings, etc. must be placed on reverse side.). <br /> NEW INSTALLATION- (No septic tank or seepage pit permitted if public sewer is available within 200 #eet,) <br /> PACKAGE TREATMENT' [ ] SEPTIC TANK j ' Size.._...4 ----•-------•----.-•-•••••••• Liquid Depth ...........:..... ... . <br /> -- <br /> Capacity ........ Type'••................. Material......_-._..----_ 7. <br /> No. Compartments <br /> Y <br /> ...-•-•......... <br /> pF...-. <br />} + l Distance to nearest: Well - Foundation ....__•--•- --- Prop. Line ................. <br /> •- ---------------- = <br /> ., s <br /> LEACHING LINE j No. of Lines --------------- Length of,each line------------ - ---. Total Length .................11.......... <br /> ..� ! 4 <br /> D' Box Type Filter Material ......... .......Depth Filter Material --------•......__--__...........--•---•--:. <br /> I .. <br /> Distance to nearest: Well ........ .............. Foundation- _-..~`::..:._..*...... Property Line --•-O•---•--•....� i <br /> SEEPAGE: PIT ( } Depth ..................... Diameter !-_.-.--...... Number -------------_------------ <br /> Rock Filled Yes No <br /> 1 Water Table Depth ` Rork Size ,y <br /> Fation <br /> ound ------------------ rap. Line :----.... <br /> Distance to nearest: Well k <br /> REPAIR/ADDITION(Prev. Sanitation Permit <br /> .......:............ ..•--`-- Date - '•-:°.:--•--- <br /> f t, <br /> {Septic Tank (Specify Requirements} :............. .: - ..... '... .. _..: <br /> --- <br /> . J �►' <br /> Disposal' Field (Specify Requirements} .....� �[E'. :...�_-----=:_ �� � <br /> 3 �. <br /> } - ..-•--------------------- -- _ . .-•.......... .--....--.-_--....--.-__.. <br /> -------- .................. S <br /> ----•--•---- - <br /> {Draw existing-------- --- s g and required addition-on reverse-side) <br /> F <br /> I 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 Ilcan <br /> sed agents signoture.certifies'(the following: . .' ' <br /> "I certify that in the performance of the work for which this permit is' <br /> issued, I shall not employ any person in'such manner <br /> as to become subject to Workman's Compensatiori,laws'of Califcr l." <br /> Signed Owner <br /> • <br /> By .............. Title <br /> (If oth on ownery! <br /> I " FOR DEPARTMENT USE ONLY <br /> i yc ,y . -'Z DATE .:... ... _...-....... <br /> I <br /> APPLICATION ACCEPTED BY - r <br /> -------------- -•:::.t--•:..........- <br /> BUILDING PERMIT ISSUED • . ..... .. .................................... <br /> L ->.�..... ....._----- . DAT _._-.. � <br /> ADDITIONAL COMMENTS _!— :. ' •• r <br /> ==:- :::::: :__:_:::: .... ......::::� :::::::::: :: : <br /> _.. <br /> ---------------------------------------=-::..........---------...--•.:....---- ---- .._.. ----•----.......--•-----.-.....----------•--.....-.._-.._....- - .. <br /> Cr <br /> .................: Date Final Inspection by: Dae ...._... . _. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> i <br /> r u13 24 1_�A Rev_ 5M <br /> 7/721,, , ,— <br />