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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> .................................................. <br /> [Complete in Triplicate] Permit No. ..7. ..�7:..._.. <br /> This Permit Expires 1 Year From Dat*Issued Date issued ....-......... .... <br /> Application is hereby made to the Son Joaquin Local Health District for a per to construct and install the work herein <br /> described. This application is mode In compliance with County Ordinance No, 549 and existing Rules and Regulations.- <br /> JOB <br /> egulations:JOB ADDRESS/LOCATION ....... ....... ..... ..... _ _.._......................................CENSUS TRACT .......................... <br /> Owner's Name ...... ....... .Phone ........._ ..................... <br /> Address ....... --_... . Gv__�_. City ��x� •---------•--•....................... <br /> Contractor's Name ..... ------1.._�--- :�. _ �.,.Lieense #� A.. Phone .............................. <br /> Installation will serve: Residence ❑Apartment House C] Commercial {]Trailer Court C <br /> Motel ❑Other -------------- •----•.f-•••--......... <br /> Number of living units:.....lf_----- Number of bedrooms ___,:_..Garbage Grinder ....... Lot Size ......... ........ <br /> Water Supply: Public System and name ........................................................................................ .......Private <br /> Character of soil to a depth of 3 feet: Sand E] Silt[ — Clay ❑ Peat❑ Sdir dy'Loam {Clay Loam ❑ <br /> Hardpan ❑ Adobe.E3—Fill Material............. If yes,type ........_-_____________ _- <br /> (Plot plan, showing size of lot, location ofsystem 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 TANK f ] — -_ —size:.......-...:"... ............................ Liquid Depth ---------------- --------- <br /> Capacity .................... Type .... ............... Material---------............. No. Compartments ...................... <br /> Distance to nearest: Well ....................................Foundation ...................... Prop. Line ................. <br /> LEACHING LINE [ ] No. of Lines ------------------------ Length of each line---------------------.------ Total Length ............................ J <br /> D' Box Type Filter Material .Depth Filter Material <br /> Distance to nearest: Well ._.._...__•_____________ Foundation ........__..._ --------- Property Line .................. <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(Prev. Sanitation'Permit# .............. ... .............. Date ....--------_-_----_- ........ <br /> SepticTank (Specify Requirements) ........................ .............•-- --- -. ......................................................._.............._...---•-••----•-- .� <br /> Disposal Field (Specify �R�eJcpuirements) ..� ---.. ..........................•-• <br /> ^' <br /> ,�y <br /> ---A f -----T 4�. , . ..... ......... <br /> ------------------------._.-........ <br /> .------------------------------------------------- <br /> .........----------- ` <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 mann*r <br /> as to become subjectto Workma 's Compensation laws of California." <br /> Signed ......... •.................. ....... Owner <br /> B Title' f ._........ <br /> Y .... ................. .... ... . ...... . ............ <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY .. ............................ DATE .o.--ey-.Zy..___....• <br /> BUILDINGPERMIT ISSUED .........................................................................-................I................DATE ....................... ................... <br /> ADDITIONAL COMMENTS .._....•••--------------------•----•-------...... ................................ ..................................... <br /> .................--•-------.......----._..........--------......:....---..............---...---••------------------•------.._.......--------• -------------------------....... <br /> ................. <br /> ........ .. ... ---- •----------------- <br /> Final inspection by: .L _............................................................................Date - f:�., . ............. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 13 24 1-'68 Rev. 5M 7/72 3 M — <br />