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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> .........................._......................•- Permit No. ._.�. ...��. <br /> r (Complete in Triplicate) <br /> _.._..._....... <br /> ­---­------------------............... <br /> ......................................................... This Permit Expires 1 Year From Date Issued <br /> Date Issued .-1:.3 7Z <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 m de in compliance with unty Ordinance No. 549 and existing Rules and Regulations: <br /> �v Zl/ -4) <br /> JOB ADDRESS/LOC Ss/Loc ON ... ....-- ---.�"-°P '... ......................CENSUS TRACT .......................... <br /> Owner's Name ....,..R ...... 4i[.,?... .. .... ....... .............I.................ev................Phone .....-... .........I......-----..._. <br /> AddressC <br /> - -Q � .�. ............ ... - ....... ity ...... .U•Vbl��l!�.%.f '........... <br /> Contractor's Name ----- ...... ` ... A.......... ,.License # .AVAP..,3-F K. Phone .............................. <br /> Installation will serve: Residence Apartment House f] Commercial ❑Trailer Court <br /> Motel ❑Other -------------------------------------------- <br /> Number of living units:...-.-/.--- Number of bedrooms _.___3---Garbage Grinder ............ Lot Size ............................................ <br /> Water Supply: Public System and name -------------•--•-----------•-....._.................-•---------------------................_.. .............Private <br /> Character of soil to a depth of 3 feet: Sand E] Silt❑ Clay ❑ Peat❑ Sandy Loom Clay Loam ❑ <br /> Hardpan ❑ Adobe 0 Fill Material ............ If yes,type ............... ............ <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 TREATMENT [ ] SEPTIC TANK f l Size................................................ Liquid Depth ........................ <br /> Capacity -------------------- Type --.......----------- Material.....-..----------•--- No. Compartments .....................� <br /> Distance to nearest: Well ....................................Foundation ...................... Prop. Line ......................p <br /> LEACHING LINE [ ] No. of Lines ------------------------ Length of each line............................. Total Length ..........................5 <br /> 'D' Box ..--------.. Type Filter Material --------------------Depth Filter Material ............................................ <br /> Distance to nearest: Well ..................... Foundation .................__--_ Property Line .....-_.........,...... <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ........... Number ...................... <br /> Rock Filled Yes ❑ No 0C. <br /> Water Table Depth ----------------------- ------.......Rock Size ........... .................... G <br /> Distance to nearest: Well ............................... --Foundation -------------------- Prop. Line ..................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ............................................ Date ----------........................ <br /> ) d <br /> Septic Tank (Specify Requirements) ................. ... <br /> --•-•-- . . ...4.. _....--•----••-------'----•---••..............,.._....................._..... !... <br /> Disposal Field (Specify Ire uirements F O" <br /> ---------------------------------------------------._ <br /> - ... <br /> - <br /> 4 <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 Joaqultt <br /> County Ordinances, State Laws. and Rules and Regulations of the San Joaquin Local Health District. Horne 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, 1 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 /> BY --- ---•----------•- ------------------ -- - ----- �. Title --- <br /> {If --. ..._. <br /> other than owner} <br /> _-_- FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ------ <br /> - - - ------------ ---•-•------.. DATE .....f...----.:..---- -�- •----...: <br /> BUILDING PERMIT ISSUED ------ -------•---• ----------------------------------------------------------- ..........----------..DATE ..._......---------...---------- <br /> ADDITIONAL COMMENTS ------------------ <br /> ---------------------- ---•-------------------------------- --------- ---.....---- ----- ------------ --.......-- -----....... .. <br /> ---------------------------••-------- ---....... <br /> �.. �....__........_. <br /> Final Inspection by: ..._..._... ..............................Date . <br /> ..............•-••---- <br /> EH <br /> 13 2L 1-68 Rev. 5m SAN JOAQUIN tOCAL HEALTH DISTRICT 8/7h 3M <br />