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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> Permit No, <br /> ----_----------;IV- ----------------------------*--- lComplete in Triplicate) <br /> .......... <br /> Date Issued <br /> - This Permit Expires I Year From Date Issued <br /> .. <br />..................................I........ .............i ,. - <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 mode in compliance with 6UhtV%OrdInonCe No. 549 and existing Rules and Regulations. <br /> JOB ADDRESS/LOCATION .. .....................................CENSUS TRACT ............. <br /> ... <br /> ............. ...-Phone <br /> Owner's Nome <br /> City . ....... ........... ...... ........ <br /> Address ............ <br /> #o�P3,�.-3Y3.... <br /> .. ..............License <br /> Contractor's Nome .......... <br /> Installation will serve- Resiclen&&[Apartment House E3 Commercial E]Traller Court 0 <br /> Mote] C1 Other ........................................... <br /> Lot Size ....... <br /> Number of living units:..... ..... Number of bedrooms 3......Garbage Grinder <br /> Water Supply: public System and name ...................................................................................... ......................Private I$ <br /> Character of soil to a depth of 3 feet- Sand L] - Silt[3 Clay 0 peat 0 Sandy Loom 0 - Clay Loorn [3 <br /> Hardpan AdobeM Fill Material ..........-If yes,type ............... ............ <br /> (Plotpion, showing size of lot, location of system In relation to wells, buildings, etc. must be placed an reverse side., <br /> NEW INSTALLATION- (No ibotic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT C—] SEPTIC YKN_K tF Size-.... ...........................- Liquid Depth ........................- <br /> Capacity----- --------- Type ............... Material...................... No. Compartments ......................N <br /> Distance-to nearest:..Well,,- 7.... ......................Foundation ....................... Prop. Line ..................... <br /> LEACHING LINE No. of lines ---------_------------ Length of each line.............. ............. Total Length ........... ................ <br /> 'D' Box ............ Type -Filter Material ..Depth Filt6r,Material ............................................ <br /> Distance to nearest: Well ........................ Foundation _........... Property Line ........................ <br /> SEEPAGE PIT Depth Diameter --- ............ Number ............................. Rock Filled Yes ❑ No 0 <br /> Wa-ter Table Depth _Rock Size ................... <br /> ter ---------------------------------------- <br /> " . ....... <br /> Distance to nearest- Well ---_...Foundation ................ Prop.JUne .............. <br /> REPAIR/ADDITION(Prev. Sanitation.Permit# .-t............... ........ ........... Date ........................•......... <br /> Septic ank (Specify Requirements) ----------_--_--- ........ ........... ............. ........ ............I......... ............................. <br /> ....... ------- ...... .............._7............ <br /> Disposal Field (Specify Requirements) - --------- - <br /> ".",--- f> I <br /> ....----••.... ....................­_­.................. <br /> ...............__------------I—------------------------ ------f__TS."_X2_- <br /> ............. .....................................................;.......... <br /> ---------•------••------- --------------- ------ --• I------------------------------------- 6n­reverse side) <br /> (Draw existing and required ad41`4 <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with Son Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Jpacluin 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 /> -------------- <br /> Title ...... ................. ............. ....... .......... <br /> by ------- ------- <br /> (if �e Irt owner) <br /> FOR DEPARTMENT USE ONLY <br /> DATE <br /> APPLICATION ACCEPTED BY ---- ................. <br /> BUILDING PERMIT ISSUED -----------) ....... .............. DATE --------- ---------------- <br /> .................... ...........................­­........................... <br /> ADDITIONAL COMMENTS .... <br /> .....................-1-------- <br /> -------------- ---------- ---- <br /> ---------------- ............. . ....... ... /: <br /> ............---------•----- <br /> ----------- at <br /> ... ----------- ------ --------------------- ----------- ------ e <br /> Final Inspection y- --------- ------------------------------------------• ­­---------- ....... A <br /> EH 13 2h 8/7h 3M <br /> 1-68 SAN JOAQUIN LOCAL HEALTH DISTRICT <br />