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FOR OFFICE USE, <br /> ...... ........_...............I—.......I........ APPLICATION FOR SANITATION PERMIT <br /> ....... .I——........................... (Complete in Triplicate) Permit No. <br /> ...... ............... ....................... This Permit Expires I Year From Date Issued Date 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 /> JOB ADDRESS/LOCATION <br /> ---I...•... ..... . <br /> .. <br /> Owner's Name .... .........CENSUS TRACT .......................... <br /> ....... <br /> ........................................ <br /> Address .......... -------.......­*..........Phone <br /> ...... Phone .?.I........... <br /> W........ city ................ <br /> -- ----------------------••-•-••---.....----................ <br /> ------------------------------- ............ ........... <br /> Contractor's Name License # Affgl$"?77...... Phone.......... <br /> Installation will serve. Residence UKApartment-House 0 Commercial oTrailer Court <br /> Motel 0 Other <br /> ................... <br /> Number of living units:...../..-- Number.of bedrooms __..:....Garbage Garbage Grinder ------ ..... Lot Size ............ <br /> Water Supply., Public System and name ...... ........... <br /> -------------------......................... ❑........................... Pr.i,vote <br /> Character of,soil to a depth of 3 feet. Sand Silt C] Pea t 0 <br /> C y 0 Sandy Loom 0. Loam E] <br /> Hardpan ED Adobe M6terial .........._ if yes,type <br /> .......... <br /> Mot 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 [ I SEPTIC Size............ - <br /> .............................. Liquid Depth ...... ...... <br /> Capacity ................••- Type .....................Material.._---.-_. .. No. Compartments .......... .......... . <br /> Distance. to nearest.. Well ............ 00 <br /> .........................Foundation ...................... Prop. Line ....................... <br /> LEACHING LINE No. of Lines. .................. line..._..---..---_...:- 6' 1 <br /> V Box .......... Length of each ...... Total Length .................. <br /> - Type Filter Material ------...............Depth Filter Material <br /> Distance to nearest. Well ........... ............................... <br /> ........... Foundation ......... -------- ..... Property Line .............-, .L_,- <br /> SEEPAGE PIT Depth .------------------- Diameter ---­-------_ Nummber ............................ Rock- Filled .-Yes!-[:j _ -No-(:3' <br /> Water Table Depth ............................ ❑ <br /> --------_-_-----Rock Size ................ . 00 <br /> Distance to nearest: Well .............................. ---------Foundation ............. ...... .Prop. Line ....... ------ <br /> REPAIR/ADDITION(Prev. Sonitotion'Permit# ........... <br /> Septic Tank (Specify Requirements) ...... .............. ................. Date ­­............. <br /> ..................... .................... ............................. ........ . . <br /> Disposal Field (Specify Requirements) ...4.71.. _ -Z <br /> _ 44_4t .. .....�W ......... ............... <br /> ............ <br /> A-4 4. .......v;::....... ......... <br /> ---------- <br /> ............................. -----------------­------- .................... ---------I......... <br /> ----------- ................. .................. ...................... <br /> ad_di'�ion on reverse side) <br /> (Drow,existing and required .............. <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 Son 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 subibct to Workman's Compensation laws of California.,, <br /> Signed .............. <br /> ------------ ..... .............. <br /> Owner <br /> By <br /> ......... .................... ............. ........c1n, f_ Title <br /> (If other than owner) ...................... ............ <br /> F1 Id'R1 <br /> .........­...........-...-...-...-...-.......-..... <br /> ..-.-.--.D-.-.-.C-.-.P�-A RTMENT�--U---S�--E----O--N---L--Y <br /> APPLICATION ACCEPTED BY .. .. ..BUILDING PERMIT ISSUED ..... - -- <br /> -------- . . DATE <br /> .......................o <br /> ADDITIONAL COMMENTS ... --- -" -- --------- .............DATE .e. <br /> ...I—..—.. <br /> ....... <br /> ................................................... ...... ..................... ......:............... <br /> ..................._.­................... ................................. ................:....... <br /> ............... ......... ........... .............. <br /> ............................................ .........................11...... <br /> --­----------- ..................... ............................. <br /> -------------------------------- ----------- ................ ...................... <br /> ............... <br /> Final Inspection by: ...... ............... ...............7............................................... ............ <br /> ---------- <br /> ................................................................Date ........ <br /> ,.SAN-JOAQUIN -LOCAL HEALTH DISTRICT <br /> E. H.13 241-'68 Rev. 5M. <br />