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FOR OFFICE USE: <br /> ............. APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit Na �... -. �.% <br /> �. <br /> ......................................................... This PermltExpires 1 Year from Dote Issued <br /> Date Issued <br /> Ap otion a <br /> y made to the San Joaquin Local Health District for a permit to construct and install the work herein <br /> de cri md. Tcationis,rg�a compliance with County Ordinance No. 549 and existing Rules and Regulations:�JJOADD ETIO ..- <br /> 1 � _/ ....- CENSUS TRACT ......... :............ <br /> Owner's Name ...f I" . .. : .. -�r .............................................................. ... ........ ... .Mone .,..:_... ,.. ...................... <br /> 1 <br /> Address _l- .� .�_. .- ." City .. .- ... ..4' .. - . ..............•.. ._. <br /> Contractor's Name ---- �a'L�'z� _._ l? ? �r.- _..4 ...aK��:..license # .�s 3 Phone ....... .................... <br /> � <br /> Installation will serve: Residence Apartment House❑ Commercial[)Trailer Court 0 <br /> MotelQ Other............................................ (A <br /> Number of living units:---f------ Number of bedrooms 5_._.Garbage Grinder ............ Lot Size ........ .. ...... :....., :....... <br /> Water Supply: Public System and name ..--•-•----•-----••...............:_...................---•-----...........-.................................Private <br /> Character of soil to a depth of 3 feet: Sand❑ It❑ Clay ❑ Peat❑ Sandy Loam 0 Clay Loam ❑ <br /> Hardpan Adobe❑ Fill Moterlal ............ if yes,type............... ............ <br /> is <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 spit permitted If public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT ( ] SEPTIC TANK 1eep Size. '��. .� - - ......... Liquid Depth Z..............,. <br /> Capacity�, 2?-..---- TypeAi!�: Material_.._ :? >C3_. No. Compartments ................... <br /> Distance to nearest: Well .......... . .. .........Foundation _..1C? .._ Prop, tine .....fir . <br /> LEACHING LINE [e"'No. of Lines ----�--------------..---•----_.-- length 'of each line........ ............ Total Length ... a........... • <br /> 'D' Box -- ...... Type Filter Material .... ��...Depth Filter Material ......,/`T............................ <br /> Distance to nearest: Well ......�rG� ... Foundation .......1'�J .. Property Line ..�'� ...... <br /> ` ...... Rock Filled Yes Q�No �❑ <br /> SEEPAGE PIT [ Depth --- -_-_.. .... Diameter ... _ ...._ Number .....,. ............ <br /> Water Table Depth ..........I.C%C%/ ...Rock Size'../. <br /> Distance to nearest: Well ........... l.'r1 ___.._Foundation ..._/..Uprop. Line ..... .... ... .... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------- ------ Date ..................................) <br /> SepticTank (Specify Requirements) .....................-------- ................................................................................................................ <br /> DisposalField (Specify Requirements) ------------ ---•--------....._..----...---------------•--------------..._.....---------..._...........----...---•------............. .. <br /> ------------------------------ ---------•----------•--. .................................. .................. ---.......... ..................................................... <br /> ---------------------------------- ----------------------------- .....-............-.................................. ......................................................... <br /> v (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 rkman's Compensation taws of California." <br /> Signed --------- -• Owner <br /> By ----- ------------- � `/ - Title .- .�C�C..I`� <br /> - _------ <br /> 2e <br /> (I er than owner► // <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -- - . -- ............... .. . -. ----­­­__7----- DATE <br /> BUILDING PERMIT ISSUED ----- -- - -. -__......... -- - ----•----------•---.. .- - -------- ----------- -- DATE . ... ..... ...._.. ......•....--•---. <br /> ADDITIONAL COMMENTS ..... .....-------- <br /> ---------- <br /> ......------------ - ---------1 -...---------------------- <br /> - ------------- -_........-- ......... --------- -------- ------------ ........... .............. __.....------------....... .......... .. <br /> .............. ........................ ..............-.............-..........-_..............-........... <br /> ... <br /> :;:�e................ <br /> Final Inspection by: ....Date - . "-- -- <br /> EH 13 2h 1-68 Rev, SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7b 3M <br />