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FOR OFFICE USI:': <br /> APPLICATION FOR SANITATION PERMIT <br /> .....................---------- ----- Permit No. <br /> (Complete In Triplicate) <br /> ... � . <br /> i ........... .................................•----_.... _. S 7� <br /> This Permit Expires I Year From Date lssded flats 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 compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> - <br /> JOB ADDRESS/LOCATION .. _ �........ . .........................CENSUS TRACT .............:..:......... <br /> Owner's Name . .......... ...::...: Phone <br /> Address -----......•.....................••. ......... ....... <br /> City ...--•-• . •----- ................__ <br /> / <br /> k / ....License #/,,,A ... Phone .� <br /> Contractor's Name . ��.... . .. ................ .; <br /> Installation will serve: Residence©Apartment ouseA Commercial{]Trailer Court Q <br /> Motel ❑Other.-•..�....Golba a Grinder .!�...__ Lot Size��_ ..�Z._ .....' <br /> Number of living units:- .1___.... Number of bedrooms g � J....-.•..-•---- <br /> Water Supply: Public System and name ------------------------------------..........................................................................Private 0 <br /> Character of soil to a depth of 3 feet: Sand 0 Silt❑ Clay ❑ Peat[) Sandy Loam❑ Clay Loam' <br /> { Hardpan p 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: a (No septic tank or seepage pit permitted if'public sewer is available within 200 feet,) <br /> 4 PACKAGE TREATMENT -SEPTIC TANK Size.................. ............. Liquid,Depth _----_--- <br /> Capacity ----- Type -- p <br /> ---�-•-•------ ---••-----.._.:. Material---•----------------- No. Cam artments�•--�_............--•-•- <br /> Distance to nearest: Well ..... ............................. <br /> .Foundation► -- --•--------•-_-.... Prop. Line'_.i................... <br /> LEACHING LINE [ ] No. of Lin L gth of each lin Total LengtF�............... <br /> s; 1 D' Box_____________ Type filter M er#al ____.__.___..._._...Depth .Filter aterla) ' <br /> . ......-----•. <br /> R = aistance;to nearest: Well Foundation ----------- ...... Property Line ........................ <br /> Dia eter, <br /> .... '........ Roc Filled Yes <br /> � NoDe s <br /> Water Table Depth --•----- ---- ....... ............Rock Size ..... . ...... Q <br /> 1 Distance to nearest. Well ... ...... y <br /> - ----------�-•----------------- ........._..._. Prop. Line '..... <br /> (Prey. Sanitation Permit# ................ ._--------- Date ----------- ----_ <br /> Sept:c Tank jSpec+fy Requirements) .................... .............................-------•• •---• ---)- <br /> ---.._... ..---• ................. <br /> I <br /> Disposal Field (Specify Requirements) ---- --- ) ,--- L`---:€ ClST7!! ..... <br /> - <br /> �!/y'(Draw existing and required addition on reverse side) <br /> I.hereby certify that .1 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 Heolth:District. Hotne'owner or Ilcen- <br /> sed agents signature certifies the Fallowing: <br /> "I certify that in the performance of the work for Which this permit is Issued, I shall not ee p cy,any persons in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed _. --- ---- - Owner <br /> t (If other than oeri +. <br /> _ FOR DEPARTMENT USE ONLY r <br /> APPLICATION ACCEPTED 8Y --- 1--•iJ . .... !.- --------------------------------•----------------------------. DATE,...---- "7�------ <br /> BUILDING PERMIT ISSUED •-----•..............•- ------------DATE ..............•---------------------------- <br /> ADDITIONALCOMMENTS ._...-------••----------------• ...................................I.._..........I----------- ---------•---....... --......_....r:_.......................... <br /> ----- - - --------------------- ---------------------•-------------------------------- ------•------- ------------ ---------.----------------------- ............................. <br /> •------------------------ ----__. •-•----- •-----------------•------------•--•---------------------------•-- ------- ----------- <br /> Final Inspection by: ----------- ---- /i.,...... --------------_-•-- ---•- -- <br /> ••- ------........:-----Date .-.... h� •-moi --------- <br /> EH 13 2h 1-68 Lev• SAM JOAQUIN t:OCAL HEALTH DISTRICT 8/74 3M <br />