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1 <br /> FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> ---�- - Permit No. .7................ <br /> ............ ........ (Complete in Triplicate) <br />_......... .. -3/ 7J <br /> ..... This Permit Expires 1 Year From Date Issued Date 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. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATI N .. �� .....-Q."- .—.....•.................................................CENSUS TRACT <br /> Owner's Name , .. Phone ....----°19 L1 ....... <br /> Address ... . .............................,.................................. City ........ <br /> Contractor's Name ............... --------------------------------------------------------------License # ........................ Phone .............................. <br /> Installation will serve: Residence WAportment House 0 Commercial ❑Trailer Court 0 <br /> Motel ❑Other............................................ ` <br /> Number of living units:............ Number of bedrooms ............Garbage Grinder ............ Lot Size .....1 !.......................N <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 ❑ 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 /> 4�►''� Capacity .................... Type .................... Material-------- ............. No. Compartments ..................... <br /> V Distance to nearest: Well ...................................:Foundation ...................... Prop. Line ...................... <br /> LEACHING LINE [ ] No. of Lines ........................ Length of eachline............................. 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 �L--1„ <br /> Water Table Depth .............Rock Size <br /> Distance to nearest: Well ........................................Foundation .................... Prop. Line ...................... <br /> EPAIR/ADDITION(P v. Sanitation Permit# ............................................ Date ....._.........................._.) <br /> Septic Tank (S Requirements) -------------- -- -.--•-•--._........._..- -----._. ...._WU.1...._Di oFiel (Specify Regv ement I ..._=lSo- -- - •-�'11�,� ........-•----....... <br /> ._.. -. +Ls.r --- . ...._.. ....-•-•--. ---... _.._..... <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 Son Joaquin Local Health District. Home owner or licen- <br /> sed agents signature certifies the following: <br /> "I certify that in the performance of thp work for which this permit is issued, 1 shall not employ any person in such manner <br /> as to becomes ect to Workman" pensation laws of California." <br /> p <br /> Signed 4- ._._._ ..... <br /> Owner <br /> By ....................................................................................................... Title <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY .... -• -----------------------------•----- ---------------._.._.............". DATE ......... "'. .....�....�.....-. <br /> BUILDING PERMIT ISSUED .... ..... .....DATE ........................ <br /> ADDITIONALCOMMENTS ...............................................................................•--• ...................................................................._•--•-- <br /> ..............•-----•--•••......--•-••--•••......................-•-........---_..............-•---•-------•-•--..........-•-•••.....•-•....-•---•..........._......._..........---....-•-•--............ <br /> ............................................ ........................................... <br /> ........................................... ... ........_.._...._.........--....-,.-----•.--.-•---........-..................,...._........ y� ....•. <br /> Final Inspection by: ....... <br /> _ JC�� ..�—..................... ..............Date ....—1 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H.13 241.'68 Rev. 5M 7/72 3 M <br />