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FOR OFFICE USE: <br /> y ,�, APPLICATION FOR SANITATIONI PERMIT <br /> -------- -------------------- --- --- - Permit No. Z 5 <br /> (Complete in Triplicate) 1 , 4 <br /> Date Issued <br /> This.Permit Expires 1 Year From Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a permit toconstructand install the work herein <br /> described. This application is made in compliance with County Ordinance No. 549'and existing Rules and Regulations: ! <br /> ~ <br /> JOB ADDRESS/LOCATION <br /> .�1 r - ------ ------------- ---------- -- ------CENSUS TRACT .------------------------- <br /> Owner's <br /> -------------- - ---- <br /> Owner's Name -� ----------- `-----------?Ph_one ----- I <br /> Address l,� -. lY_ .�� ., - Y �b <br /> -------------- cit <br /> Contractor's Name . __ ___._ __ � <br /> �-- ------.License #�.S' � ,3.. Phone bra- - - <br /> Installation will serve: Residence ❑ Apartment House❑ Commercial:❑Trailer Court ;❑ i <br /> Motel ❑Other _/Z/«r¢j.._.-. _ <br /> f E <br /> Number of livin.g units:------------ Number of bedrooms -- ---------Garbage Grinder ------------ Lot Size ---- ------------------------------------- <br /> Water Supply: Public System and name --------------------------------- ------------------------------------------------------- -------------------- <br /> Private" <br /> Character of soil to a depth of 3 feet: Sand'r —Silt0--Clay, Peat Sandy Loam Clay Loam <br /> Hardpan Adobe❑ Fill Material ------------ If yes,type ---------------------------- <br /> (Plot plan, showing size of lot, location of cyst m in relation to wells, buildings, etc. must be placed on reverse side.) W I <br /> NEW INSTALLATION:! (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) O <br /> PACKAGE TREATMENT,; [ ] SEPTIC TANK'[ ] Size d... <br /> 41__X----- ------------- _ -- Liquid Depth ----tea- ----------- <br /> 1ii tCapacity OQ._- --T.Type Material-d cl4G,t'1�iNo. Compartments ..le.............. <br /> f .i - :„ 'V <br /> t <br /> Distance to nearest: Well --.:-Z....................Foundation ----/ - Pr p. Line _.f,G9..__"_.._ <br /> LEACHING LINE [ ] NotoLines ....1----------------- Length of each line./.Q,`�i'��1�x/�r ength ----------------------------- <br /> ff s / <br /> D' Box ----- ...- Type Filter Material - ¢. __Depth Filter Material!_.--- - ---­----------------- <br /> Distance to nearest: Well ... ,0--.......__ Foundation ..,fes- - • Property Line -- ______________ <br /> SEEPAGE PIT Depth Diaireter ------------------ Number ___---------------------- Rock Filled Yes No <br /> `Water Table Depth ------------------------------------------------Rock Size ------------------'------- <br /> 1?istance <br /> ----.-Distance to nearest: Well ------------------ --------_--_-......Foundation ---...- --------- Prop. Line .................. <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ---------------------------------- <br /> Septic <br /> ._._.._..._._.....__.____:_._...Se tic Tank (Specify Re. uirements <br /> Disposal Field (Specify, Requirements) ------------------------------------------------------------------------------="=-----"---------------------------------------------- <br /> ------------------------------------------- <br /> ----------------------------------------------------------- - <br /> - --------------------------------------------- - <br /> - --------------------------------------------------- <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 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 beco ubject to Workman's Compensation laws of California." I <br /> SignedOwner o <br /> ------- r --- --------- <br /> SY --- --- --------- ------------------------------------------ Title _ <br /> - -------- - - <br /> (If other than owne <br /> t � <br /> FOR DEPARTMENT USE ONLY t <br /> APPLICATION ACCEPTED BY -W------`-O-------- DATE ------------------------ <br /> BUILDING PERMIT ISSUED I <br /> - ----DATE ------------------------------------------ <br /> --------------------------------------------------- <br /> ADDITIONALCOMMENTS _Y-------------------- ------------------------ -------------------------------------------------------- ---------------------------- <br /> ------------------ ------------------------------------------------------------------------------------------------------------_.--------------------- <br /> -------------------- ----------------------- ----- <br /> Final Inspection by ..�: ► ---------- ------ -- --------------------- - ----------------------- Date -3 � ' <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT i. <br /> t ' <br /> I E. H. 9 1-'6$ Rev. 5M <br />