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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> . ..........d........ <br /> .. Compets in Triplicate) <br /> _.-..-._._ � _ 'S <br /> •••••Permit No <br /> ..........".............. fi <br /> This Permit Expires 1 Year From GoM Issued <br /> Date Issued f . .:�. <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 compi nce with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCAT1 �� 6�0�Z'eP,. <br /> �.._...--_--.7.._ -t.1 ....-.. - <br /> -.•................CENSUS TRACT <br /> Owner's Name ...... ...................Phone,tn,, 1.14�.,�, <br /> Address ............._.......... ....... <br /> ....City ... . ............................... <br /> Contractor's Name ... ...C.....: .license # Phone <br /> Installation will serve: Residence bPApartment House 0 Commercial(]Trailer Court fl <br /> Motel❑Other............................................ <br /> Number of livingunits:..... Number of bedrooms ..� <br /> ...•• .....Garbage Grinder ....:....... Lot Size .�i�:..2�..f......... <br /> Water Supply: Public System and name ............................................................................... Private C].•.•......... <br /> ................................ <br /> Character of sol to a depth of 3 feet: Sand 0 Slit C3 Clay 0 Peat 0 Sandy Loam 0 Clay loam Q <br /> Hardpan Q Adobe D Fill Materlol ............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 /> NEVA INSTALLATION: (No septic tank or seepage pit permitted if public sewer Is available within 200 feet,) <br /> PACKAGE TREATMENT [ j SEPTIC TANK{ j Size....... ...... Liquid Depth <br /> Capacity.................... Type .................... Material..................... No. Compartments ...................... <br /> Distance to nearest: Well ....................................Foundation ....................... O <br /> Prop. Line V► <br /> ...................... <br /> LEACHING LINE [ j No. of lines ........................ Length of each line.._..._.. ._. <br /> *­... <br /> 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 [3 <br /> Water Table Depth ..... .........................................Rock Size ................................ <br /> Distance to nearest: Well ........................................Foundation .................... <br /> Prop. Line ............... . _ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# •-•--..._..... Date .................................. <br /> Septic Tank (Specify Requirements) ............... ..............::...... -........... <br /> Disposal Field ( pecifr Require eats) .. __... . ... . . ............... 2 ..................... .... ......................... <br /> I <br /> G/). <br /> .-••--._..�. _���:-� :`_. . . , _-� .............._ .........................................I........_---__ <br /> (Draw existin nd r uired addition on reverse side) <br /> I hereby certify that I have prepared this application and that the work will be done In accordance with Son Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Hoa* 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 o ork�� Compe at n Iowa f California." <br /> Signed -- , <br /> :_. ._. ....._ Owner <br /> ................... <br /> By ..................................... ................ Title ... ... <br /> (if other than owner) <br /> DEP TMENT USE ONLY <br /> APPLICATION ACCEPTED BY . <br /> BUILDING PERMIT ISSUED ................................ DATE .I /'.................... <br /> ..............................................................I. ..DATE <br /> ADDITIONAL COMMENTS <br /> ........--.. 1�....• .... .............. <br /> final Inspection by: ..-...... . �In:."�...................... ...::...... ...............:..,......Date .......�2... 2 <br /> 7... ........ <br /> N JOAQUIN LOCAL HEALTH DISTRICT <br /> c-u 13 24 2--AA a.,... -- <br />