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"FOR OFFICE USE: <br /> ` APPLICATION FOR SANITATION PERMIT permit No. ------------_------- � <br /> ----------------------------------,•-------------------- <br /> (Complete in Triplicate) <br /> --------------------------------------------------- <br /> ----- <br /> _----------------------------- This Permit Expires 1 Year From Date Issued Date Issued <br /> -- -- <br /> Application is hereby made to the San Joaquin Local Health District for a per n-iit to construct and install the work herein <br /> described. This application ismadein compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION __471W---I.~:f lND---o--- -------------------- ----------CENSUS TRACT`-------------------------- <br /> Owner's Name ------------- - ------------------------------------•---------------------------- ------Phone --------------------•--------------- <br /> Address -----" i-g_l 1)-)P,u-------=------------------------------------ ------- -- City �r > <br /> Contractor's Name --- ----------------- �--- -----------------------------License # ---------.--------------- Phone ------------------------•- <br /> Installation will serve: Residence ❑ Apartment House❑ Commercial '❑Trailer6 ®� <br /> Mate!-❑-0ther— =='� -------------z---•-- �. <br /> Number of living units:---/-------Number of bedrooms ---a-----Garbage Grinder �____ Lot Size __-----�__-___- ---------------------- <br /> Water Supply: Public System and name ----- ---------- -------------------:-------------- ---------------- -------------Private Ej -^ <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt:0 Clay ❑ Peat❑ Sandy Loam -❑ Gay'Loam:❑ <br /> Hardpan ❑ Adobe D�Fill Material ------------ If yes, type ---------------------------- <br /> (Plot <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 /> PACKAGE jv <br /> TREATMENT [ I SEPTIC TANK![i ii Size_____` ----------------- Liquid Depth ____---- -____._._.. . <br /> Capacity _jQ00-------- Type __lRC2S ---- Material_ Qct� <br /> No. Compartments _"__`.2,______.____ <br /> i <br /> Distance to nearest: Well _______�y_______________________Foupn�d�a,tion ---------------------- <br /> Prop'. Line _!!___ __._.:...__ _ <br /> LEACHING LINT: [ ] No. of Lines ..---�--------------- Length of each line___.aV--____.._.____._ Total Length ____1!�Q____ <br /> 'D' Box Y��----- Type Filter Material _ __ .___Depth Filter Material -------I.l _---------------------------- <br /> -Distance <br /> ___________ -___._Distance to nearest: Wel[ --.-r� -------__--- Foundation .--110- --------- Property Line ---- -•.-__-_-- •-- <br /> SEEPAGt"PIT -.[ j Depth --------____________ Diameter ------------- _. Number _----_-_ Filled Yes ❑ No i❑ <br /> ---- ---- ------ <br /> oc <br /> WaterTable Depth ------------------------------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line............------------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date --_---------.-_-------------------) <br /> Septic Tank (Specify Requirements) -------- --------- - -------------------------------------------------------- <br /> ------------------- .------------------ ------ <br /> DisposalField (Specify Requirements) ---------------------------------------------------------------------------------•----- --------------------------------•---------- <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. 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 shalt not employ any person in such manner <br /> as to became lett to Work n' ompensation laws of California ' _ ...._ <br /> Signed v_ <br /> —` .s <br /> - - ---- °-�. --- - - -- - ------------- --------------------- --- ------- -- Owner <br /> BY ------------------------------------------------------------ --------------------- --------- Title -------- =--- ----------------------------- ------------------------- <br /> (If other than owner) <br /> FOR DEPARTMENT US <br /> APPLICATION ACCEPTED BY ------------------------------ - --- ----- ---------- = DATE --- �7�7_ -9 <br /> PERMIT ISSUED --------------------- -------------DATE ---------------------- <br /> -------------------- <br /> ADDITIONAL COMMENTS --------------------------------- ---------------- ------=--------------------------- <br /> -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> -----------------------------=-- - ----- -- --- - --------- - --------------------- ------------------- ---- -------------------------------------- ------------------------ <br /> = ---------- <br /> Final inspection by: ----------------------------------------------------------------------------- .�.' "MDate .6-` _ __0 - ----------------- <br /> SAN JOAQUIN LOCAL HEALTH ISTR1CT <br /> rte' <br /> E. H. 9 1-'b8 Rev. 5M <br />