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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) <br /> Permit No. <br /> ... \ This Permit Expim 1 Year From Dote,issueDate Issued .7 <br /> Application is hereby made to the San Joaquin local Health District for a permit to construct and install the work herein <br /> described.TTfUs application is made n c mpiiance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATIONN. 1- z ' � t� _'_� l I x`..12 .. CENSUS TRACT <br /> Owner's Name ...........r ..1�r:Ur. ..... <br /> .L�.. 1 .._.. r• ....Phone ......... <br /> Address ...................... .. City .......:�.. <br /> Contractor's Name ....... .� I .. - �elkense ��i Phone .....................:...... <br /> Installation will serve: Residence❑Apartment Hou e❑ Commercia D oiler Court <br /> Motel 0 Other —� <br /> Number of living units:............ Number of bedrooms ...... .Garbage Grinder .. .......... <br /> Water Supply: Public System and name ............................ .............. lot Size .........,....................... <br /> rn.Private <br /> Character of soil to a depth of 3 feet: Sand❑ Silt E] Cloy ❑ Peat 0 Sandy Loam [a Cloy Loom y <br /> Hardpan Q 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{ ] Size ' <br /> ................................... ......... Liquid Depth .......................... <br /> Capacity .................... Type .................... Material...................... No. Compartments ...................... <br /> Distance to nearest: Well ....................................Foundation...................... Prop. line ...................... <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 [ ) Depth .................... Diameter ................ Number ............................ Rock Filled Yes ❑ No <br /> Water Table Depth ................................................Rock Size ----_.__-------.-.----------- <br /> Distance to nearest: Well ....................................Foundation ....... ........... Prop. line .. . ..... . <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ............................................ Dote ............................... .) <br /> Septic Tank (Specify Requirements) ................ .............. .........._........... <br /> Disposal Field (Sp ify Requ rem: is) .... �. .... ................ ........... <br /> .- c�. I �....... �� .../ .. ... ..... ../.......... . ... ,�2- ....... ....... ......., �.� ... ..--- <br /> .................................... •-•-- ..............---...... ......... ................... .M.... ......... ........... .... ` <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 whir Sen Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or Nun- <br /> ,sed agents signature certifies the fallowing: <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 ensation laws of California." <br /> Signed -------- ................. . Owner <br /> BY C 3'itle <br /> C <br /> (if other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ...�..:.. <br /> ..... . ................................ <.............................. .... DATE .. ........... .................. <br /> BUILDING PERMIT ISSUED ""' ' <br /> .DATE ..................: <br /> ADDITIONAL COMMENTS """ <br /> .................................................................................................................................. <br /> Final Inspection by: ................. . .. .............. ................................................................................. .r9. ............................ <br /> ........ ..............I....................................._.Date /lL ...................,............. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> c_w 13 24 _... _ _-• <br />