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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> ---- ----------------------- - -------------- <br /> (Complete in Triplicate) Permit No. <br /> This Permit Expires 1 Year From Dote Issued <br /> Date Issued <br /> -------------------------------- ------------ --- <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. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION .- S�l �-- ----- Gc3 J- CENSUS TRACT - .- --------...--- <br /> Owner's Name ----- <br /> ----------------Phone ------------------------------------ <br /> Address _.... _f'f ------ -- ----- - - -------- ----------------- City ---------------•----------------------------------------••- <br /> �.3�Y-._ Phone -----------------------_----- <br /> Contractor's Name License # 1� . <br /> Installation will serve: R idence Apartment House❑ Commercial ❑Trailer Court ;❑ <br /> Motel []Other -------------------------------------------- <br /> Number of living units:---- ------ Number of bedrooms -!F;�-----Garbage Grinder --- -------- Lot Size ---- � �-_ <br /> CT - - <br /> Water Supply: Public System and name .----------------------------------- ----- -----------------------------------------------------------------Private <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam;. 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 available within 200 feet,] <br /> PACKAGE TREATMENT [ SEPTIC TANKT&I Size- -r <br /> 01 <br /> PACKAGE Liquid Depth -�----- ----- Opp <br /> Ifti <br /> Capacity --10 4- Type P ------ Material-fX?0_-y%-e------ No. Compartments ___J--------------- <br /> Distance to nearest: Well ------------ ---------------•Foundation ------9 ------ Prop. Line -----4............. <br /> LEACHING LINE [ No. of Lines --------Z------------- Length of each line--.---g®_-f--_____--_--_ Total Length --- °---------------- <br /> -1/ aQ <br /> 'D' Box --- ---- Type Filter Material ------59-. ----Depth Filter Material ------1-1 ---------------------- <br /> Distance to nearest: Well -------Su........... Foundation -------f-0............- Property Line ---'s------------------ z <br /> SEEPAGE PIT [ ] .. Depth -------------------- Diameter ---------------- Numbe- -.-------------------------- Rock Filled Yes ❑ No C] <br /> ' <br /> 'Water Table Depth ------------------------------------------------Rock Size --------------------------- <br /> Distance to nearest: Well ----------„----------------------------Foundation -------------------- Prop. Line -----------.---------� <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) . <br /> 00 <br /> Septic Tank (Specify Requirements) -------- --------------------------------------------------- ---------------------------------------------- ----------------------------- ip <br /> Disposal Field (Specify Requirements) ---------------------------•---------- --------------------------------------------------------------------- ------------------------ <br /> --------------- <br /> ---------------t--------- - ------------------------------------------------------------------------------------------------- ------------------------------------------- <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 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 manner <br /> as to become subject to Workman's Compensation laws of California.” <br /> Signed - ------ ------------ ------------- Owner <br /> �1 10 �-'" ----• Title.��/ 1'l '--------- -- --------------------------- <br /> By -- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ------ -------------------------------------------------------- DATE --- 3 '- d----- ----------- <br /> BUILDINGPERMIT ISSUED ---------------------------------------------------------------------------------------------------------DATE - -----------•----------------------------- <br /> ADDITIONALCOMMENTS -------------------------------------------------------------------------------- ---------------------------------- -------------- ---------------------------- <br /> --- <br /> -------------------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> !� _ _ -------------- - -- <br /> Final Inspection by 'I �w• Date j '/-3.'- C1 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> i 1 '68 Rev. 5M <br />