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FOR OFFICE USE: <br /> --•-------------- APPLICATIION FOR SANITATION PERMIT <br /> Complete In Triplicate) Permit No. .---.•............... <br /> ....................4...................... ......... This Permit Expires I 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. 544 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCA <br /> � � � <br /> TIN � ...-- .- ti..............�............................CENSUS TRACT ...-.-......-............. <br /> Owner's Name .... --/- __... ------ -- ............ ........................-...........................Phone ...... ........................ <br /> Address -_-.._14._5," L1_1(__�-ac-l- .. <br /> -....----z .•----....._._ .. ... - --•-... city ....................-._.....-. <br /> Contractor's Name ....---- -•--- /��3c� <br /> Installation will serve: Residence[3Apartment House❑ Commercial ❑Trailer Court. 0 <br /> Y <br /> Motel ❑Other .._...................................... <br /> Number of living units------1--_-- Number of bedrooms ....3...Garbage'Grinder ............ Lot Size .... ............. <br /> Water Supply: Public System and name ........................................................--....................................................Private ❑�' <br /> Character of soil to a depth of 3 feet: Sand o Silt❑ Cloy ❑ Peat❑ -Sandy Loam ❑•-- Clay Loam D <br /> Hardpan Adobe 0 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 /> NEWNEW INSTALLATION: <br /> GENST ALLATION: (No septic tank or seeps pit permitted If public sewer Is available within 200 feet,) <br /> TREATMENT .[ ] SEPTIC TANK f Size__-` -� ...g.�..?'_ -,.. Liquid. Depth -- .../..............� <br /> - - Capacity ------ Type. ------------ - No. Compartments <br /> Distance. to nearest: Well -------------✓`.4../-±_............Foundation ______ Prop. Line -•---url/'f I.. <br /> LEACHING LINE [ No. of Lines ____2--------------Length of each Zine-......4�-b_•h..... Total Length :, - ......... <br /> 'D' Box ......L_-- Type Filter Material ......S_�.....Depth .Filter Material ......ZY.... .......................:.. <br /> Distance to nearest: Well ___._���.. --______ Foundation' , Property Line -_.E14. .......... <br /> PIT [ Depth ------s _' Diameter _. -�_ ...... Number ..._....__Z............. Rock Filled Yes p�No � <br /> SEEPAGE / <br /> .,...� Water Table Depth ____ ........ ...............Rock Size --.1..`��. <br /> 5 <br /> r� .....:_.-Foundation ., TT <br /> ��.- Prop. Line . l ..... <br /> Distance to nearest: Well ..._-.---.1__O.a__ . ..---• �•-- .___. <br /> REPAIR/ADDITION lPrev. Sanitation Permits# _._..._...._............................... Date -------------- ............. _} <br /> SepticTank (Specify Requirements) .........................................----.......................•................:............................___-_-..-_-........... <br /> Disposal Field (Specify Requirements) ................. ---•-• ---------••-•-------------------------------------_------•_-------- .......-_-_-------- --,-------- <br /> -----------------••-----------__-_----------- ------- --------------------­­---------- ---------------_. -------.--...................---................................... <br /> (Draw existing and required addition on reverse sidel <br /> Ir 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 HeaI&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 anmploy.any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed _------- --- Owner <br /> p....� 4" er„�......_ <br /> By -----------------------1'_1 -- :•-" Title <br /> (If other than owner) <br /> DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY _.---- --••- --•- ------------------------------• --- -------- DATE .. .: .. . . ..._.-...----- <br /> BUILDING PERMIT ISSUED ----------------------•-- --• ----------------------•-----•---- ----._DATE'........................................ <br /> : <br /> ADDITIONAL COMMENTS - <br /> --------------------- -=•----•- ••-•----•--- .......................... <br /> .. ....... ---- • <br /> ............................... . ..._ <br /> - -------------- ---------------- •-•----- ------- ---•----- ------- ----- ------ .............. --..- ....................- <br /> DateFinal Inspection ...... . .......................----- ------------- --------------- A--- • -..-------- <br /> I <br /> 13 1-68 Rev. S N JOAQUIN LOCAL HLTH DISTRICT 8/7h 3M <br />