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' FOR OFFICE: JUSE1 <br /> APPLICATION FUR SANITATION PERMIT ` z; <br /> e (Complete In Triplicate). .^ Permit No. <br /> ............... / <br /> ,r . ...... .... ..11a,�. . . ...... . This Permit Expires f Year From Date Issued Date Issued <br /> Applicationis hereby made to the San Joaquin Local Health District for'a permit to construct and install the work Mersin <br /> described. This application is made In compliance with County Ordinance No. 549 and existing Rules and Regulotionso <br /> ;1oi3 ADDRESS/l0 N9/ ::�I-'`�"`' .. ' " ... " ..... .................CENSUS TRACT ... <br /> 7 <br /> Y T . .. _. .. .............. . . .,,.....,..........,.. <br /> Owner's <br /> No, <br /> . �7 ........ <br /> -- Phone- <br />. Address . ......... ,�, . f....�� j. .:..... City, � ........ .. ............ . .................... ... ' <br /> Contractor's Nam ..... :. '4 ...License t!'•' .. ,t -� Z Phare ......:....................... <br /> Installation will serve: Residence�partment Houses] Commercial{]Trailer Court Q <br /> Motel [,l Other............................................. : <br /> Number of living units:._ . .... Number of bedrooms ......2 Garbage Grinder ............ Lot Size ._. .......�-: . <br /> . ........... <br /> Water Supply: Public System and name ........- , •........................................ ....I..................................:......Private <br /> Character of soil to a depth of 3 feet: Sand E ; Silt 0 Clay 0 Peat 0 Sandy Loam [3 Clay Lam <br /> Hardpan-a -Adobe 0 Fill Materia) ......•.....if yes,type............: . ............ <br /> )Plot plan, showing size of 'lot, location of system In relation to,wells, buildings, etc. moat be placid on reverse sids.� <br /> ,..-. <br /> NEW INSTAILAT'1 (No septic tank or'seepago pit permittee# if public sewer Is available within 204 feet,) � ';- <br /> PACKAGE TREATMENT SEPTIC TANK ] Size................. . . ...:.. ................. liquid Depth .... ...............,.. <br /> Capacity ...................... Type--..`... . .. ....... Materltal.. ........... .:.. No. Compartments . :.,..... ....a.. . <br /> Distance to nearest: Well ....................................Foundation ..................:... Prop. Line ....................... <br /> LEACHING TINE [ ] 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 ................ �II <br /> SEEPAGE PIT ] Depth ..................... Diameter .' . ......... Number .... ................. Rock Filled Yes ❑ No (3 <br /> Water Table Depth _ _............................................Rock Size..... <br /> .................,... .. . 0 . <br /> Distance to nearest ........................................Foundation .. .............. Prop. line .:,. .......,.. <br /> REPAIR/ADDITION 1Prev. Sanitation Permit 0 ............ ............................... Date .................... .I <br /> Septic Tank (Specify Requirements) .._:.-...:.._-........................... ..._ ....:...... <br /> ............._.. ............................ ...-----.......................''i.. <br /> Disposal Field (Spec) Requirements] ..................................................= ........:... " ..._..... - ............. <br /> .:.� <br /> :....... :.. -. " ..... .... ..... ..: .......... <br /> /rDr e i tin and re uired addition on <br /> _ ._._.... ........ -� ............................ ....................................... , .............. <br /> q reverse 081- . <br /> I hereby certify that 1 have prepared this application and that the work will be efone In accordance with San Joaquin <br /> County Ordinances, State laws, and Rules and Regulations of the Sen Joaquin Local Heal&Distdct. Home owner or lice& <br /> sed agents signature certifies the following: <br /> "1 certify that in the performance of the work for which this permit is Issued; 1 shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed ............. _ ' <br /> Owner <br /> BY ----......................... .............. ... ......... Title <br /> I'l (If other than owner) <br /> FOR DEPARTMENT USE ONLY ' <br /> APPLICATION ACCEPTED SY..---....�'.. ..-•- -� -......-..................................:.--•..................... DATE ..�..�:: -....................... <br /> ----= <br /> BUILDING PERMIT ISSUED ...... . .............. .. ...........--..•-••-•............. DATE ...___.............. ................. <br /> ADDITIONAL COMMENTS ....................................................................... <br /> .....................:..-.................-............-.....:..........,................ <br /> ........................................................------- -- = ..-........ <br /> -.-.-...-.........-------------------------------------•---------...-........-.-......- <br /> Final Inspection by. • ----- <br /> --- X. -- ---- .............................................-....................... Dat -. <br /> �. <br /> EH 13 .24 1-613 ttev. 5M SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M <br />