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FOR ` APPLICATION FOR SANITATION PERMIT <br /> --.- - - - -- - � Permit No. _�_. . <br /> (Complete in Triplicate) <br /> --- - 44— the <br /> _ <br /> This Permit Expires 1 Year From Date Issued Date Issued _ --------------- <br /> App <br /> :�_S_-)- <br /> App;. „ . San Joaquin Local Health District for a permit to construct and install the work herein <br /> described. T is application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> /� <br /> JOB ADDRESS/LOCATION .--- - -�,,5 LJ_5-------P'-----U ri,,_s - >--------- "�°.� � -----------------CENSUS TRACT -------------------------- <br /> Owner's Name �� ------ ------------------------------------------------- ---- :---------.Phone -------------------------------•---- <br /> ��rr r ! <br /> Address -.--..--- �� ------- _a-'"-7 ` = � — - city <br /> # .2b _ <br /> Contractor's Name ------ <br /> ------------------------ - a Phone <br /> Installation will serve: Residence r�Apartment House❑ Commercial ❑Trailer Court ;[] <br /> Motel ❑Other -------------------------------------------- <br /> Number of living units:---_I----- Number of bedrooms ----3,----Garbage Grinder _ ___ Lot Size ----.--t ---------- <br /> Water Supply.Supply: Public System and name ----------------------------------------- ------ -------------------. - ------------------------------------Private [� <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt[] Clay Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe ❑ Fill Material ------------ If yes,type ------------__-------------- <br /> (Plot <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 seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [4 Size_____ ____________ Liquid Depth -------�-----------. fi <br /> Capacity _/-J,_cr-0------ Type Material---- No. Compartments ___2............... <br /> 1 � C <br /> Distance to nearest: Well ______.�_______________________Foundation ------1�D___�_______ Prop. Line __ ________ ______ V4 <br /> ' 1 � <br /> LEACHING LINE [ ] No. of Lines -------- _--------- Length of each li e._-_/-------------- Total Length ,_ ------- INV <br /> 'D' Box __ .___- Type Filter Material�/Aea_. Depth Filter Material --_ ---_____�___________________ <br /> Distance to nearest: Well _------�_--_ ___ Foundation ......14) Property Line _-_�__._._ <br /> SEEPAGE PIT [ ] Depth _62-16--------- Diameter __ ,3 _____ Number --------- _____________ Rock Filled Yes 2No i❑ <br /> Water Table Depth -----------------------------T ------------Rock Size -------------------- <br /> T <br /> Distance to nearest: Well ------------------------------------------Foundation -------------------- Prop. Line -_-_-___-._________-__ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ____________________________i__- ------ Date _-__----______-____-______________] <br /> Septic Tank (Specify Requirements) ----------------- <br /> ------------------------------------------------------------------------------------.------------------------ ... <br /> Disposal Field (Specify Requirements) I:- __�. .----------------- <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 Son 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!! <br /> Wo man's Compensation laws of California." j <br /> p <br /> Signed ---- `--/-/— -------------------------------------- Owner <br /> BY -------------- ----- ----- Title ----- ---------------------------- -------- ------------------- <br /> (If other than owner) <br /> 43 FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY _________ _ _ _ _ __ -----. DATE __.(r7:�'9-P-�------------- <br /> BUILDING PERMIT ISSUED -- ----------------------------- -------- - -._._.DATE ....... <br /> ADDITIONALCOMMENTS ------------------------------------------------------------------------------------------ -------------------------------------------------------------------- <br /> - --------------------------------------- ---------------------------------------------------------------- --------------------- <br /> ------------------------------------------------ --------- ---- <br /> - <br /> FinalInspection by: -------------------- ------ --------------------------- ------------------------------------------ -----------------Date <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'b8 Rev. 5M <br />