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F6k OFFICE USE: APPLICATION FOR. SANITATION PERMIT <br /> .....................................-............. Permit No. _... .. <br /> (Complete in Triplicate) <br /> This Permit Expires 1 Year From bate Issued Date Issued ..3..-..•..._. <br /> 1-11.................. ......... -------------- <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 /> �/ a �/ <br /> :' -.... ...... - -----W-s---- ...CENSUS TRACT ..........•. ...... <br /> JOB ADDRESS/LOCATION ,1.:.... ... <br /> w. <br /> Owner's Name . ..... . - -•--......-•..............•--•--.-...._.._...-.... ...._..._......---.Phone .................................... <br /> Address ..._.� .�)� •u✓•••..-.................. ....................... City ............................................. <br /> Contractor's Name .�E --....License # -7/-.1 'C. Phone <br /> Installation will serve: Residence Apartment House 0 Commercial ❑Trailer Court 0 <br /> Motel ❑Other __._...•..............•----•----••------•-- <br /> Number of living units:__.__. Number of be rooms __ Garbage Grinder ^'��''.- Lot Size ..... ... .......................... <br /> Water Supply: Public System and name ...... -.� _ •_L�-�__ _. .. 0���---- -.•.....- -• �••••`�['�°�'Ld� <br /> Character,of soil to a depth of 3 feet: ,_Sand n;. Silt❑ Clay ❑ - Peat❑, -Sandy1oam fD_Cioy.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 /> I <br /> f <br /> PACKAGE TREATMENT [ ] SEPTIC TANK ' Size._` r .f1. -••-_---- Liquid Depth _-_"_��................... <br /> Capacity/A4_0V.e,0WType 04G.l 4,AZC Material. No. Compartments ...Am.............. <br /> Distance fio6gearest: Well -lee, .......................Foundation --------- Prop. Line .._�a.............. <br /> LEACHING.LINE bf No. of Lines ..----�7............. Length of each line-.._._s ... Total Length ••.h ..�_--••-•.Z <br /> ..�.rr..r_ 'D' Box .../.... Type Filter Material ./'42647....Depth Filter Material .._,� '"_�......................... y <br /> Distance to nearest: Well /a.a............ Foundation ..fes.........______- Property Line sS.... <br /> ,. . <br /> SEEPAGE: PIT [ Depth _s _J-. ........ Diameter�� .4-n...,.j. Number --- :Y ._...... Rock Filled Yes j� No C,• Water Table Depth Or..................... Rock Size ___.�----.............•-•-•-- <br /> . <br /> r it <br /> Distance to nearest: Well ____ .. .................... Foundation __ ........ Prop. Line ... ............ 1. <br /> REPAIR/ADDITION(Prev. Sanitation Permit'# ............................................. Date ..........................•.......) <br /> SepticTank (Specify Requirements) ----------•------ ..................................... ..................................................••................................. <br /> DisposalField (Specify Requirements) •-------------•-•---••--•---••-•----------------• ------------------------------_-----------------------•-•---------------------- <br /> ---------------- ----------•--................................................................ ----------------------------------------------------------- ­-------------------- ............. <br /> ----- -••----------_.._...---...--- ----------------------- <br /> .__........ <br /> ------------ <br /> (Draw existing and required addition on reverse side) <br /> 1 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. Borne 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 ..... .......I_-_-_--•--_- �. � ._._._ Owner <br /> y� <br /> By ------ ......... ••--•---------------- Title _..... ._.... ..__...._...._ __..__.....-... <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY--••-•- - ••....--- •- --- ------ .............•---------------------- ---•----•-•• DATE ...... ._ ...6a�'�'�......---------- <br /> BUILDING PERMIT ISSUED ..�.............. -------•--•---•-•---•---.... DATE _.._.._..__............. <br /> ADDITIONAL COMMENTS ...................................•----...._._..--•--------............ --•- ------------,......•.................... <br /> _.._........:.. <br /> --------------•----•------- ..............._ ............................. •--•-•-----------•----••-•---....---••------•-•... .................................... .....___.__-. <br /> ..-----•-------•--------•---•............. . .. ...... <br /> ------------- --- <br /> Final Inspection by: ----- --.._. ................................... <br /> Date ._... <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H.1.3 241•'68 Rev. 5M -- 7/72 3 24 C <br />