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POP- <br /> FOR OFFICE USE: ,� ,, APPLICATION FOR SANITATION PERMIT _1cq <br /> ..... a <br /> (Complete in Triplicate) Permit No. ......7._. ../.... <br />•...•.•................................................. This Permit Expires 1 Year From Date Issued <br /> Date Issued ... <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 N54 and existing Rules and Regulations: <br /> A •�rz <br /> JOB ADDRESS/LOCA�T "N ....CENSUS TRACT <br /> Owner's Name . .. ...... ....................................... ........Phone ........ <br /> ......... ............... <br /> Address ....L....� ......... . ................................................ City <br /> .�.....-. . .......................................... <br /> Contractor's Name .. j ° � M ✓c...c: E........License # .��.Y 3 /! Phone .............................. <br /> Installation will serve: Residence Apartment House Commercial ❑Trailer Court 0 <br /> Motel ❑Other ............................................ <br /> Number of living units:...... _.. Number of bedrooms .......? .Garbo a Grinder ............ Lot Size .-... <br /> Water Supply: Public System and name __....... ................._............_..._...._............. ...............Private <br /> Character of soil to a depth of 3 feet: Sand D Silt❑ Clay ❑ Peat[j 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 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 I ] Size................................................ Liquid Depth .......................... <br /> Capacity .................... Type .................... Material...................... No. Compartments ......... <br /> Distance to nearest: Well ....................................Foundation ...................... Prop. Line .....................N <br /> LEACHING LINE [ ] No. of lines ........................ Length of each line............................. Total Length ............................ <br /> 'D' Box ............ Type Filter Material ....................Depth Filter Material ............................. <br /> Distance to nearest: Well ........................ Foundation ........................ Property line ......... <br /> SEEPAGE PIT O Depth .................... Diameter ................ Number ............................ Rock Filled Yes ❑ No p3 <br /> Water Table Depth .......................Rock Size ..... -10 <br /> Distance to nearest: Well ........................................Foundation .................... Prop. Line ..._...._..........0— <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ............................................ Date ..................................) <br /> Septic Tank (Specify Requirements) .................................................................. <br /> Di sal Field (Specify Requirements) :....A^ '............................ . .............. <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 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 /> "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 Compensation laws of California." <br /> Signed ......... r�---------•. _-.... . .. Owner <br /> By -----................. .. lite A,.. <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY . ........ .... . .............. DATE .,a2.w�......7 <br /> BUILDING PERMIT ISSUED ................................. ........._.........._. <br /> .................................................._........................................_..............DATE <br /> ADDITIONAL COMMENTS ..... ................................:........................... <br /> ........................•-•---•--•............_................---•-•-•---.._..................._.....-----.........:_......--•--........................._............................................... <br /> Final Inspection by: ......._... . ..........................................................................Date a ... .......... ........... <br /> .......... <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H.13 241-'68 Rev. 5M 7172 3 M <br />