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....................................................... APPLICATION FOR SANITATION PERMIT <br /> (Complete In Triplicate) Permit No. .2! 4�� <br /> ........................................... This Permit Expires 1 Year From Oafs Issued Date Issued <br /> Application Is hereby made to the San Joaquin local Health District for a permit to constrict and install the work herein <br /> desaibed. This application Is made In compliance with my Ordinanco No. 549 a existing Rules and Regulationst <br /> JOB ADDRESS/LOCATI ...... Q. .. ....... , <br /> Owner's No .v.V `' ... ' CENSUS TRACT .............I............. <br /> Address ........ .. .. •:f c.JE.,. ....... ..Phone .. ........ <br /> - �.j <br /> Contractor's Name ....... . . ,. tY .........��.! .......,... <br /> �"#' .. Phane�... .. .'.��.. .'. <br /> Installation will server Residence❑Apartment HouseAlCommerclal❑Trailer Court ❑ <br /> Motel❑Other. <br /> Number of living unitst..,f�l Number of . ,,,,...................., . <br /> Water - rooms...... .Garba�Gr�l�nd��e�r.-':��fat Size .... ......... ....... <br /> Supplyt Public System and name <br /> Character of so€1 to a depth of 3 feet: Sand❑ Silt . ...............................PrlVcft* . <br /> ❑ Clay ❑ Peat❑ Sandy barn ❑ Clay Loom o <br /> Hardpan❑ AdobeA r Fill Material........... if type............... .. <br /> Yes. .......... <br /> (Plot plan, showing size of lot, location of system In relation to well <br /> NEW INSTALLATION: :, building:, etc, must be placed an reverse side, <br /> (No septic tank or seepage pit <br /> -•�-------.�.. Per ................................................if.public sewer is available within 200 feet,( <br /> PACKAGE TREATMENT { ) SEPTIC TANK( J Z*lS�-1 zeLiquid Depth ..................... <br /> Capacity .................... Type .................... Material...---................ No. .. <br /> . � Distance t Compartments .................... <br /> o nearest: Well' .foundation <br /> LEACHING LINE ...................... Prop. line .................... <br /> No. of Lines ......... ......... Length of ch ch Ilne.. .,� !..`......... Total len #h .1.. �. <br /> 'D' Box .,�..... Type Filter Material 1'4 .....Depth Filter Material ............ <br /> Distance to nearestt Well AW­�A- 47-'Foundation ../ .............. Property Line •.. .�. ...... <br /> SEEPAGE PIT Depth s '......... Diameter `.t. ............... .........-- <br /> Number Rork Filled Yes; No <br /> Water Table Depth ...................................Rock Slze .�.t' <br /> Distance to nearest: Well . ............ ....Foundation .1 .... ,'. <br /> REPAIR/ADDITION(Prev. .: Ct ................. <br /> ...................................... Prop. line .......... <br /> ( re Sanitation Permit f Date �- <br /> Septic Tank (Specify Requirements) .. ! .............................. <br /> Disposal Field (Specify Requirements) ._ c• _!/ ` .. .. .W ......... <br /> ...................... . - . ......41 ... t � 5r ...... <br /> ....._... ..V:.._.._ ... ._ <br /> .......................... .......................I.........._.-- <br /> { <br /> Draw existing and required addition on reverse side) <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County 0MInauces, State Laws, and Rules and Regulations of the San Joaquin Local Health Distrid. Home owner or Tian• <br /> sed agent:signature certifies the following: <br /> 60 <br /> 1 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 Compensatlon laws of California." <br /> Signed ..... ........... ......... Owner <br /> By ......... . title <br /> ......--.... . ... .......... <br /> 1 other than owned ..... ................................. <br /> �. . FOR PAIRTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ................... �s .... <br /> BUILDING PERMIT ISSUED .. .................................... <br /> 17 <br /> ..DATE <br /> ADpITIQN,AL COMMENTS ••-•......................•-------.............-..... <br /> Final Inspection b. ........ . .. .... <br /> .- .. ..................... .. .................................... <br /> .... <br /> Y:-- ..--• <br /> . .-•. -: -r. s. ............................ ............................ ate .. ..,.` <br /> ..........D ....... <br /> EH 13 2!r 1-6a lay. 5k - .....��....................... <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M <br />