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FOROFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ................................................I........ <br /> 77-/,f7 <br /> (Complete in Triplicate), Permit No: ..................... . <br /> .. .......... ..................... ........ <br /> ............. <br /> ..................................... 11 <br /> ............... This Permit Expires I Year From Date Issued Date Issued -.3•_:-�.?:2 <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 Regplationst <br /> JOB ADDRESS/LOCATION .0.0 ?5 <br /> ...... .. . <br /> ... ....... ................CENSUS TRACT .......... ........... <br /> Owner's Name ...... .....................................................Phone <br /> . ........................ <br /> Address ------------------- . . ...................... <br /> .................... City ........... ................................................ <br /> Contractor's Name .. 4� <br /> ------�; ..... -----._.License # ..... Phone .................. <br /> ............. <br /> Installation will serve: <br /> Residence C1 Apartment House 0 Commercial oTraller Court 0 <br /> Motel C]Other ..................... <br /> ................... <br /> Number of living units............. Number of bedrooms ............Garbage Grinder ......... Lot Size ................. <br /> Water Supply. Public System and name ........................................... <br /> .........................I........4..........I........................Private <br /> ❑ <br /> Character of soil to a depth of 3 feet: Sand Silto Clayo peato Sandy Loam o Clay Loam o <br /> Hardpan El Adobe f] Fill M6terIo1 <br /> ............ if yes,type .......................... <br /> {Plot plan, showing size of lot, location of.jystern- , in relation to wells, buildings, etc. must be placed on reverse side,}' <br /> NEW INSTALLATION:. <br /> (No septic--tank or seepage pit permitted If public sewer is available within 200 feet;) <br /> PACKAGE TREATMENT SEPTIC TANK ................ Liquid Depth ..... ....... <br /> -Size_.............................. <br /> %-., L, .............. <br /> Capacity ..................... --!I'Material Material: <br /> --::•..._.............----------......... . ............... .... No. Compartments .................. <br /> ...................... Prop. Line ......... <br /> Distance to neafe-sit Will -1�................................. <br /> 4-� ....... <br /> LEACHING LINE No.,Pf lines-:........... ....... Length of each .line_...._......... ._...._.. Total Length ............................ <br /> ............... ... . <br /> ....... Type Filter Material ----------Depth Filter Material <br /> ....... ....... <br /> Distance to nearest: Well ........................ Foundation ........ ............... Properly Line ........... .......... <br /> SEEPAGE PIT Depth ....... Diameter ................ Number <br /> ........................... R&ck Filled Yea 'o No C) <br /> Water Table Depth '......................Rack Size -----......-•----....=•-•----... <br /> Distance to nearest. Well - ...Foundation ..................... Prop. Line .................. <br /> REPAIR/ADDITION(Prev. Sanitation Permit# .........;........................ ........ Date -............................... <br /> Septic Tank (Specify Requirements) ................ <br /> I . .....--�p......I......................................................... .................................. <br /> Disposal Field (Specify Requirements) ....... ...... <br /> ............. ............................ ...... <br /> ............ ........................... -•-•--.........---..............__.._ <br /> ......................................................... ..............................................-.......-......................... <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 Son Joaquin <br /> County Ordinances, State Laws, aril 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' the work r for which this permit is issued, I shall not employ any person In such manner <br /> as to become s�ubN*ecp 1pWor orn�epsafj laws aws of California." <br /> Signed -- - - -- --------------- ........ ..................... ----- Owner <br /> By ----------- .................. . .....I <br /> ------------------------------ -------------- ------------ ---- --- -- -Title .................. <br /> (if other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ......... <br /> 7P DATE-.17-7 ............ <br /> BUILDING PERMIT ISSUED ................... ............. ..................................................j-...... ----------- .. .... <br /> -.... ---------DATE .......... <br /> ADDITIONAL COMMENTS --------------- -------------------------- <br /> ....................-...I.......j......................... ........................... <br /> -----------------------------1...................... ............................................................................... ...........-............I........... .............. <br /> ..............-.................I................. ................I.............................................................................................. .................... . <br /> .....................................;; . .....5i..a... �- .1-7 ............. <br /> 00 e. -------------------------*"*-'-.................. ................ ....... ....................... <br /> Final Inspection by: ........... .V. . .. ......................... ....Date <br /> ..... ------------------- .7 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 2411--s.&jo— =A.& <br />