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W FOR OFFia USE APPLICATION ICOR SANITATION PERMIT <br /> . ...:................................................ Permit No. <br /> (Casnplete In Triplicate) . .................. <br /> Data;Issued <br /> This Permit Expires 9 Year From Date Issued' ' <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 ounty Ordinance No. 549 and existing Rules and Regulations, <br /> JOB ADDRESS/LOCATIO �.,. a. .. ............ .....CENSUS TRACT ...................�..... { <br /> CWrie srtJome ,,d. -'`. .:::y��1 .. .........= ....:. - Phone ................................ ... <br /> Address ................ , .... .. .........City ......_...:. :............:_ ......_.............. <br /> a , <br /> Contractor's Name .. -!.?..._. . ... . ........ ...�-...- _. .._ ...-._._.:.....LicensevAhone .... .....-..-._.. <br /> Installation will servei Residence partment House Commercial (-)Trailer Court 0 <br /> Motel❑Other' ....................................... <br /> Number of living units:..... _•... Number of bedrooms'..: Garbage Grinder ............ Lot Size ... - -.......... <br /> Water Supply: Public System and name .------•--•---•................ ....................................-...............................Private <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam❑ day Loam ❑- <br /> Hardpan iK Adobe❑ Fill M6terial ............ If yes,type ...........:... ...... <br /> :. <br /> (Plot plan, showing size of lot, location of system In relation to welts, buildings, etc. must be placid an reverse side.) <br /> NEW INSTALLATIONS (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT { ] SEPTIC TANK{ ] . Size................................................. Liquid Depth .......................... <br /> Capacity ......:............. Type Material...................... No. Compartments <br /> Distance to nearest: Wel! ►r <br /> . --•-•----•-•........................Foundation ..__._._.............. Prap. tine .........---...:..... <br /> 00 <br /> LEACHING LINE ( ] No. of Lines .................... g g <br /> =--- Length of each Ilne.--•----•-•--............... Total Length .... ...:........:. <br /> `D' Box ............ Type Fitter Material ....................Depth Filter Material .........._:.......................... <br /> 40 . .� <br /> Distance to nearest: Well ........................ Foundation ......................... Property Line ......................... <br /> SEEPAGE PIT ( ( Depth .................... Diameter ...............� Number _............................ Rock Filled Yes ❑ No ❑ <br /> Water Table Depth --•............................•-••-............Rock Size __-.:........_..._:.............. <br /> ..Foundation .. Prop. 1.lns .:.............:• <br /> . Dis#arae-to-nearesfis Well...................................... ._......_..._..... .... <br /> REPAIR/ADDITION(Prev. Sanitation Permit .......•. Date ) <br /> Septic Tank {Specify Requirements( <br /> ..__;.... ... .�1..... ................................../} ^ .................. . .........?.... <br /> ` <br /> Disposal FIN10' (SecifRequirentsT . -- f • ---•- --� e ." .. •.........._ <br /> 9 <br /> .......... .4............. .ryt`:�.:..:C.......�`�......... -........ 3 J14� ... ............. .... <br /> .......... ............................................................i......... .......... ............................................................................._.............. <br /> (Draw existing and required addition on reverse side} f <br /> t hereby certify that'[ have-prepared.this application and that the work will be done In accordance with Sass Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations-'of the San Joaquin Local Health District. Hayne owner or titan- <br /> sed <br /> itemsed agents signature certifies the following: <br /> "I•certify that In the performance of the work for which this permit 1s issued, I shall not employ any pe0son Gs such.manner <br /> as to become subject to Workman's mpensatlon laws of California." <br /> Signed ....................................... ............ .......... ............ Owner <br /> ... ....... 7itie ..� ....................................... <br /> ..........: <br /> BY .........................:.-. t <br /> (If a#her than ow r) <br /> FOR DEPARTMENT USE ONLY 1 <br /> APPLICATION-ACCEPTED BY .......... .......... .. ......................... :. DATE... .f ...� ............. <br /> BUILDING PERMIT ISSUED <br /> ADDITIONALCOMMENTS ............. ................................:'............................ <br /> ................................................... ----------•-----.....................--....----...-•-.......------..........................................................._....---............ <br /> :-----... .I... <br /> Final Inspection by: ............ :.------ ...._............. ....... --........--.....-.Date ...�� ?- ......... <br /> EH 13 2h 1-68 Rev. 5M SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3H <br />