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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ... ------------------------- <br /> lComplete In Triplicate) Permit No. .- = fl. <br /> -_ .... .... This Permlt Expires 1 Year from Date Issued Date f slued ...: S__-.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 a plication is made in compliance with unty Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION ... <br /> /. /l r1Y f:NSUS TRACT ......-.......... <br /> .�'. . �f�y�_�"`+._ - --�.�r.�-�..�...� .............. <br /> ..--- <br /> Owner's NameN �t .. _... rl+_l�h ..... �- C�,� �1�. lJd�' ......... 0�_..... <br /> Phone . <br /> Address .C3... Q.. ._ ............................ ...... <br /> ..,....... <br /> ...:City ...L-is. A-56-e..4................................ <br /> Contractor's Name .................................-------...............................,..................License # .........-.............. Phone .............................. <br /> �y <br /> Installation will serve: Residence Q Apartment House Commercial QTrailer Court Q Q <br /> Motel <br /> Number of living units:__-----__ Number of bedrooms ..`:.....Garbage Grinder .._.:.7�_ Lot Size ..�...1���,��.._........ <br /> Water Supply: Public System and name -•-•-•-- ..............-........•............................................._._............................Private <br /> Character of soil to a depth of 3 feet: SandE] Silt Q Clay Q Peat Q Sandy Loam Q Clay Loam <br /> Hardpan 0 Adobe Q Fill Material ............ if yes,type............... ............ <br /> (Plot plan, showing size of lot, location of sys7de <br /> in relation to wells, buildings, etc, must be placed on reverse sid <br /> NEW INSTALLATION: (No septic tank or seep pit permitted if public sewer Is available within 200 feet,) <br /> PACKAGE TREATMENT j ] SEPTIC TANK Size-J.7-40-0............................... Liquid Depth ._.._............... <br /> Capacity _I. d_-_-. Type ..._ Materlal.G�'.A(_,69r5 o. Compartments --- <br /> _ ..Foundation D Prop. Line <br /> Distance to nearest. Wel! . ...... V....._.... <br /> LEACHING LINE ] No. of Lines .......1-------------- Length of each line.__._.:`� ....... Total length � F.......... <br /> 'D' Box ............. Type Filter Material .............-.....Depth Filter Material .......................................... <br /> Di-stance to nearest: Well .-Y---------------------�------------- Foundation ....._TP.........--- Property Line A?A.: .......... <br /> SEEPAGE PIT { ) Depth ._ .. ....._.. Diameter .3-3 ---- Number .......1...... . .. ...... Rock frilled Yes No <br /> Water Table Depth ...... . Rock Size ..,1...��....,. <br /> Distance to nearest: Well ----................Foundation Prop. Line ........... <br /> REPAIR/ADDITION IPrev. Sanitation Permit# ................................ ..-`-_ Date ....................... ......... <br /> .-} <br /> Septic Tank )Specify Requirements) . <br /> r � •--------------- : ----- •..... ------ •-•-..... --•-•---.._...:........ .._..-•----------- .... .� <br /> Disposal field (Specify Requirements) ------------------------ <br /> ---------------------•--•---- - ..........................T <br /> .....• -- .................... <br /> r <br /> -------------------------------------------------------- <br /> ....... <br /> .---------�-------------- ---••- ................... ._}_ ........--.:................`... ..................................... <br /> (Draw-existing and required addition on reverse side) z . <br /> I hereby certify that I have prepared this application and that the work-V411l be done in accordcieire with*San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health:Dlstrict. Hem* 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 to Workman's Compensation laws of California." "'e, r_ <br /> Signed -------••----=-------------------------------------------------------------------------..-------- Owner <br /> BY ------•-------------------------•-- ---•••-------------------------------- _.::. Title------- - <br /> (if other than owner) - -. <br /> FOR DEPARTMENT USE ONLY. <br /> APPLICATION ACCEPTED BY --......C`------ <br /> -------- ::" DATE Jl�........ <br /> ---------- --------: <br /> BUILDING PERMIT ISSUED --------- •----------------_- -- --------------•--•-•-•-•-_-- ----------_-- ...............DATE ----------------------_--- <br /> ADDITIONAL COMMENTS ----------------------------- <br /> ---------------•.. ---------------------- .................-...........__... ----- <br /> . ......... .........•--------------...-..------.._............ :. <br /> -------- ------------ _... .... <br /> •-----•--- -------- <br /> FinalInspection by: .............r--•--._. . ._"..-_.. _.._. _. . _..-.-..----••---.-.----•------•--• _- .........._....._...._._Date'. <br /> EH 13 2� ].-6t3 Rev. 5'�1 � � -..__.....�................. <br /> SAN QUtN LOCAL HEALTH DISTRICT 8/7h 3M <br />