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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br />•.......... ....... (Complete in Triplicate) Permit <br /> ..... <br /> �� /- 7 <br /> Date Issued ...�:....::... <br /> This Permit Expires 1 Year From 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 No. 549 and existing Rules and Regulations: <br /> LOB ADDRESS/LOCATION . . .' « . _. " .' *£.-.._............ ........CENSUS TRACT ----- -.......... <br /> ....... <br /> ... <br /> Owner's Name -. <br /> ... .............................................:.:..,..7............-----Phone . ............................. <br /> Address ........_ll... .. + .,• _.... ....... City ... - u.�....-:ems... <br /> ' <br /> e r } <br /> Contractor"s Name .. ... �>,."k ..... + !<.�license # � �'�.:�° :... Phone .............................. <br /> Installation will serve: Residence Apartment House❑ Commercial ❑Trailer Court 0 <br /> Motel ❑Other ............................................ <br /> Number of living units:-.--- Number of bedrooms ...?..-...Garbage Grinder ............ Lot Size ....< ?r. .............. <br /> Water Supply: Public System and name ................................................ ............................................ .................Private <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay 9( Peat❑ Sandy Loam ❑ Clay Loam C3 <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.)c�, <br /> NEW INSTALLATION: (No septic tank or see age pit permitted if public sewer is available within 200 feet,) V <br /> � r <br /> PACKAGE TREATMENT [ ] SEPTIC TANK Size..' 1�/ .�e ...g....X-. .'.............. Liquid Depth ... ................... <br /> Capacity <br /> v pe...... Material. No. Compartments i <br /> .......... <br /> Dance tonearest: WellrA1..•.................Foundation <br /> ..,40__A----•..... Prop. Line .....�'' .............. <br /> LEACHING LINE [}'� No. of Lines .....oR------- ------ Length of each line-------`� <br /> .-. V ------- Total Length ...5,?a / Y ....... <br /> 'D' Box ..../...... Type Filter Material .....'...".........Depth Filter Material J ...N................................... <br /> Distance to nearest: Well .... ?...`........... Foundation ..�f1.�............. Pro a Line 15 <br /> SEEPAGE PIT [� Depth ... ' Diameter .1Z...... Number .......s ..... ........... Rock Filled Yes [ No <br /> Water Table Depth ..............11--al? ......................Rock Size ......... <br /> Distance to nearest: Well .........1.00. .............Foundation ...1.4? ....... Prop. Line ... .._......_.... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ............................................ Date ..................................) <br /> SepticTank (Specify Requirements) ............................................................................................................................................ <br /> DisposalField (Specify Requirements) ..-----•-•.....................................................................................................••--------•---•....... <br /> --------------------- ----------------------- ........................................................ ---•--.....................------•..........----- <br /> --------•-------------------•-----------•-------------------------•-•---------------•--•-..............-----•--...-------•...--•---•-- <br /> (Draw existing and required addition on reverse side) <br /> 1 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, 1 shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed ... --...... Owner <br /> � . . <br /> 40 <br /> By . _. _._...... ..... Title ... . . ... ..............••••-- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> 17 <br /> APPLICATIONACCEPTED BY .........&- .....••--•..............•-•••-•••-•-•-•••--•-----•.........---••.................. DATE ....... ..' -- ................... <br /> BUILDINGPERMIT ISSUED -----------------*.................... ......................................DATE ........................................... <br /> ADDITIONALCOMMENTS .......! .e ...................................._--•--------......---..........--••--... .............................---............-----.. <br /> ...........................•------.................----...........------•--------........--•-••-•-•-----•----•----------•---.................------•----•--.....................-•-------------- <br /> ... : .............................. ...............�r.................•-•-•--•-•-...-----•.....-----••--••-----•••••-•-............-•--•-................••-• ---•'........ <br /> ... •--••.................•--- <br /> FinalInspection by: .--•----•......�-;�-•--•...............•---...........................--••--•---.............................Date .... .:.w�'.. ... ......---- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H.13 241.'68 Rev. 5M 7/72314 <br />