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FOR OFFICE USE. <br /> APPLICATION FOR SANITATION PERMIT <br /> ........ ...... .................... ...... .. Permit No. .. ..fI 7 <br /> 1Complete in Triplicate) <br />.......... .............................................. This Permit Expires 1 Year From Date Issued <br /> Date Issued <br /> lication is <br /> the <br /> in <br /> echereby noicompliance al Health District <br /> installrmit to construct 'and Regulations.. <br /> hereindsribed Thisappcatoismoden ihCounty Ordinance No. 549 and existing Rules and <br /> JOB ADDRESS/LOCATIO r�,tr�- 1"I./..... .. ........ . . .• --- -- ° ' ,...............CENSUS TRACT .. <br /> Owner's Name ......... ..... . ............ ..-•-•----. ------------------ ....................Phone .......... <br /> It <br /> City . ---- <br /> Address '--. .►�"'- � � � T C� <br /> a � ... .. .. .. ....�?_ .�. <br /> Contractor's Name - ------- ------ - ---- t.,.....License # . 3g..Phone .............................. <br /> Installation will serve: Residence I Apartment House[) Commercial ❑Trailer Court 0 <br /> Motel ❑ Other . ... - ----......... •----- <br /> Number of living units: r... - Number of bedrooms ./.._----Garbage Grinder ............ lot Size ..... ................................... <br /> Water Supply: Public System and name - ..- •-------------- ------------------- - ..........-.__...--•-----••-•-----....---•.. Private <br /> Character of soil to a depth of 3 feet: Sand❑ Silt 0 Clay (] Peat❑ Sandy Loam Clay Loam ❑ <br /> Hardpan ❑ Adobe ❑ Fill Material ------ If yes, type ........... ...... ... ... . <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings,, etc, must be mplaced on reverse side.) <br /> NEW INSTALLATION: (No septic tank or see ge pit permitter! if',public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ SEPTIC TANK [+ size, .......... Liquid Depth --- .-..---_-----_- <br /> Capacity 1.2b Type -Er +.. Moteriol.(�!'�___ No. Compartments _... '!'........457 <br /> Distance to nearest: Well 5;A!.................Foundation .....4R 1 ....... Prop. Line 'ate.,..........of each line ....Al0 ,th _ 6 <br /> LEACHING LINE /No. of Lines Length ......- ... Total Length ....`.�G. .......... <br /> 'D' Box .."" Type Filter Material ...._.5-!Q......Depth Filter Material ...... .9..��...........•................ <br /> �pDistance to nearest: Well ...... ..r-------- Foundation L tP------•----.-- Property Line .a+.................. <br /> T [if/ Depth t� .S .�.- ... Wnvap r Number /.............. Rock Filled Yes [!r000'No ] <br /> Water Table Depth . .........6.0- -------------_---_-.Rock <br /> .r <br /> Size ../...--,�._._X 3_.---... <br /> Distance to nearest: Well .......... -------------------Foundationf.. Prop. Line ......a .......... U <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------- ------- ----------------_--------- Date ----------------------------------) <br /> Septic Tank (Specify Requirements) .-..---•---------------------------------------------------------------- •. --. .............-----•--...........S <br /> Disposal Field (Specify Requirements) ---•----------------------------- -------------------- ---------------- - ._..------- -------------------- 1. <br /> ........... ......... ... ........... ....... ............ ..-... ..... . ...........----- <br /> - <br /> ------------------------------------------------------------------ -- ----- --------..-.....--------....... l <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 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 shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed . . .......... .... Owner <br /> By . Jibe <br /> ....- ... ..•. -•--- ---------------- . . .... ........•... ...... --- <br /> (If <br /> other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY `... ----- . ......... DATE .� . , . <br /> BUILDING PERMIT ISSUED . . . ..._. ... ._ ... ... . --.....---_•... ....... -. .. . .......... .......DATE . ..... .......................... <br /> ADDITIONAL COMMENTS .... ......... .... ......... ....._.......... <br /> ..------ •--•-------- • ................... --------------------- ---... . ....................-------------- ---------- .........------------------------------------------ <br /> .--------------- <br /> ....... <br /> FinalInspection by: ----------1— <br /> ........ --.......Date . <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT r� <br /> v `�J <br /> E.-H.1-3 241-'68-Rev_-5M 7/7TT7r- <br />