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OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> Permit No. . ................... <br /> .[Complete in Triplicate) <br /> ••-------------------------- •7 <br /> This Permit Expires 1 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 <br /> �� ---,� • -Re_9gu.?l.a. <br /> tions: <br /> JOB ADDRE55/LOCATI � ---------------------- ------CENSUS TRACT ------:_...- - <br /> _------_ <br /> ISCn <br /> -------------------Owner's Name • <br /> Address ----------- ................... --------- -------- ---------•-------------- City -- -••------ ---------------��9� --- <br /> j <br /> Contractor's Name -------------- -�- --- ---- - ------�---- /.�---------..License,#1VP_S_//------- Phone <br /> Installation will serve: Residence.❑Apartment House❑ Commercial []Trailer Court ❑ <br /> Motel ❑ Other - ---------------- •------------------------ <br /> Number of living units:----,r!----- Number of bedrooms __�...Garbagerinde�_.- L'ot Sia ___70---X�LO <br /> Water Supply: Public System and name ---------------------------------------------------- - ..'-. __ -'-----------------Private ❑ <br /> Character of soil to a depth of 3 feet. 5a d❑ Sip CladPet Sandy <br /> . ❑ <br /> Loam -E] Clay Loam <br /> Hardpan <br /> A- e )[ata ,,1fyes.type ------------------------- <br /> (Plot plan, showing size of lot,+.)ocation of system .ip,re)ptio.n to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No wpt iy-nk Jorsslepage pit-permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT ] . SEPTIC.ANK [ ] �` Size.. ! ,. ------ ------ Liquid Depth ----------_------------- � <br /> Capacitye .�� . -',r�-�.�Vlaten I. No. Compartments <br /> Y -: <br /> ss�, F i _ } �`Foundation -------- Pro Line <br /> Distance to ries"re's�F:•�W. 11�r._E_4." W. � P• r'r1 <br /> LEACHING LINE [ ] No. of Lines ------------------ ---- Length of each,_line ---- -------- ------ Total Length ----------_------•-•- C l <br /> 4 <br /> D' Box ------------ Type Filer Material 1..t,----',.___.....Depth Filter Material ----------------•--.-----------------•------ � <br /> 6�ce � ne�rest: Well �-----•-- = � t 'Fo 4lation ------------------ ,. Property Line ------------------------ <br /> SEEPAGE PIT f'} �'� ' ' - Rock Filled Yes No <br /> w- Diameter Nu ber ❑ 0 <br /> Water Table Depth ------- - , Rock Size ----------------------------•--- <br /> i <br /> -------- -- •---- Pro Line -_------_---•--•-- <br /> Distance to nearest: Well �-------------------af.._.______.......7Foundation - p• <br /> REPAIR/ADDITION{Prjv. Sanitation Permit# .T:_I- -______.. ---------- Date ------••-•- ----------- •--••----} <br /> Septic Tank (Specify Requirements) ------------ ---• -- .- <br /> ^c <br /> Disposal Field )Specify Requirements) -------- � � _ <br /> ------------------------------------------------------------------------ �.. -- .. <br /> -----------. ---------------._....----------------------•---- ------- --------- <br /> / ='•� 1 <br /> ------------------------------ ------------------------------------------ ------- - ------/.............-------------------------------------------------------------------------- ------------------ <br /> (Draw e�fisting and required addition on reverse side) <br /> I hereby certify that I have prepared this/Iapplication and that the work will be done in accordance with San Joaquin <br /> County Ordinances, State �q>v.s, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- <br /> sed agents signatueertfiiestlie follo <br /> "I certify that in the performance of the work for which this permit is issued, ) shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed ------------------------------------ <br /> ----------------------- -- ---------------- --------------------- Owner <br /> ----- Title - ._ --------------- <br /> (If oth <br /> ha <br /> owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ----64,,"2- -------------- ------------------------- --------------- DATE ---- /f 7�7 <br /> BUILDING PERMIT ISSUED ----------------- ----- --------------------- ------...DATE ------------------------------------------- <br /> - <br /> ADDITIONALCOMMENTS ----------------:----------------------------------------------------.......--------------------.......-----------------......---------------._...-------------- <br /> ------------------------------------------------------------------------------- --•-•---------------------------------------------• -----._.._...------------------- ---••--------•--------- <br /> -----------•------------••-----------------•-•--------- ---•-------------------•--••--•-••-------- ...............--------------------------- ------------ <br /> - - - - ----- --- <br /> - - - - <br /> ---------------------------- <br /> - -------------------- .-- - - ..� <br /> Final Inspection by: -----•--------- Date ...�.�. <br /> .. j� . ..crf�•�. --, <br /> SAAQUIN LOCAL HEALTH DISTRICT <br />