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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br />_.. ...........\0.1 <br /> . .� .f1.. b <br /> ............... <br /> (Complete in Triplicate) Permit No. <br /> This Permit Expires 1 Year From Date Issued 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 /> f` <br /> JOB- ADDRESS/LOCATiO ..�r-���...1,��`./dam.f.,,�..�. _... ......................................CEN5U5 TRACT ......:..................... <br /> G�Y1.c� .�.�.. ...... .................. ................... .................................... <br /> Owner's Name - a'................ f._. Phone <br /> Address ...... ........ -_.. . ?. .a � 1Lc. tiwln.cam._....................... City Y. " .................................................. <br /> Phone ` <br /> Contractor's Nome .....�. �laL �------------------................................License # .?1.. 5. �.� <br /> Installation will serve: Residence partment House 0 Commercial [:]Trailer Court 0 <br /> Motel ❑Other ......�-----•----•----g-•-•............. <br /> Number of living units:..... .. Number of bedrooms ..... .....Garbo a Grinder Lot Size C?`1. d ....................... <br /> Water Supply: Public System and name _..................•-•-••-••--•--...... -•--...............-----•-•--...........• .............................Private <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe 56 Fill Material ............ If yes,type..... ...................... <br /> (Plot pian, 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................................................ 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 Q <br /> Water Table Depth ................................................Rock Size ................................. <br /> Distance to nearest: Well ........................................Foundation .................... Prop. Line ........._.......... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ............................................ Date .................................. <br /> Septic Tank (Specify Requirements) ..................._.:_ .._. •--................................ <br /> ........... _._............_.. <br /> Disposal Field (Specify Requirements) l_N_ .__ ► ,d� : <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, 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 /> y <br /> - ---- Title `R- ". .-c.' . ............. <br /> If of er than owne6 <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ..__ .... ............................. DATE ..... .�._ _'.7l ... <br /> BUILDING PERMIT ISSUED ..................._......... ..............DATE ........................................... <br /> ADDITIONALCOMMENTS ------...•--....._...............................................................:...._•-•--................. <br /> .... .......................... .........._..._...-•----------•. <br /> .......................... ....... <br /> . ... ...._•.. .. . .......... ... ..... ..... <br /> ...... ... ... . <br /> Final Inspection by ........Date r --. <br /> SAN JOAQUIN KCAL HEALTH DISTRICT <br /> E. H.13 241.'68 Rev. 5 M 7/123 ,%t <br />