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FOR OFFICE VSE: APPLICATION FOR SANITATION PERMIT USE- <br /> .............. --- <br /> .��------�--...._.._.. Permit Na. ..... <br /> IComplete in Tri <br /> �``'' plicate) <br /> ......!.�f .3.1.l............. ...:........ Date issued .. ............. , <br /> This Permit Expires 1 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 County Ordinance No. 549 and existing Rules and Regulationss <br /> JOB A'DDRIESSAOCATION -. .._. .. ..± .. ..._..... ................CENSUS TRACT ...... ...... ...:.... <br /> Owner's Name -. -.. .........:............................:..:....:................Phones: <br /> Address ......... .Cta"d. . .........................City ...........:..... <br /> Contractor's Name .....• �=. .................:.. ........License � •i •!•�Phone .�. <br /> Installation will serve: Residence{ Apartment House Commercial OTraller Court 0 <br /> Motel❑Other............................................... <br /> Num y <br /> Number of living units:_.........._ Number of bedrooms :...a_Garbage Grinder ....:....... Lot Size .r. ." .,1.4.: <br /> I Water Supply: Public System and name ....._... .. <br /> ................. ........................ .........................:.......................Private Q. ...... <br /> Character of sail to a depth.of 3 feet: Sand t3 Silt(3 Clay 0 Peat QSandy loam 0 Clay Loan1101 <br /> t ` Hardpan 0 Adobe 0 Fill Materia) ............If yes,type................ ..........:. <br /> i `-(Plat plan, showing size of lot, location of system In relation to wells, buildings, etc. must be placed on reverse slda.I <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer 1s available within 200 fest,) <br /> E PACKAGE TREATMENT [ ] SEPTIC TANK{ ] Size................... ............................ Liquid Depth ................... S <br /> Capacity .................... Type .................... Material....................... No. Compartments ................... <br /> Distance.to netirest:"Well ....................................Foundation ...................... Prop. Line ...................... <br /> 3 , <br /> LEACHING EINE ( ] No. of Linea .._.. length of each line..., .... Total Length __ ............ <br /> r •...... <br /> 'D' Box :...:. Type .Filter Material .. .� .. . .Dept Filter Material .I. <<�. ................................. <br /> Distance to nearest; Well .. Foundation .. perty <br /> Pro Lute ....................... <br />' SEEPAGE PIT Depth ............ Number .... <br /> I.................... I� <br /> . Rock Filled. Yes No <br /> f Water Table !Depth ................................................Rock Size . . . .................. <br /> i Distance to nearest: Well ......... ...........................Foundation ................ Prop. Line .................... <br /> REPAIR ADDITION 1Prev. Sanitation Permit a# ..... ........ ............................. Date .................................. <br /> I .� <br /> Septic Tank )Specify Requirements) -------------- .......... ... ......._...._...............................---.. ........ .........._.,............... <br /> Disposal Field (Specify Requirements) ....... ..... ...................................................................................... . .................... <br /> .. <br /> •. <br /> �: :............... -------.---...:_......•...................................................................:_-................................................................... <br /> ---------------- --------------------------•-•--• .............._ .................... __.............................................................,............ ........ <br /> #Draw existing and required addition on reverse side) . <br /> I hereby certify that 1 have prepared this application and that the wail; will be done in accordance with Sat► Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the `San Joaquin Local Health.District. Horne owner or licen- <br /> sed agents signature certifies the following: <br /> i "i certify that in fha performance of the work for which this permit is issued, 1 shalt not employ any person In such nmanfter <br /> as to become sub ect to Work 's Campen Lia laws of California." <br /> Signed .....� �.: .�. .__��_ .-------•..................... Owner <br /> By -•................................ ..................................................... .............. Title ......... . ------------- ---......----•---..__.... ............... <br /> (lf other than owner). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ---- -er-. ...4, :': -- ------------ DATE .._ _. ...�.Q_ ..-2.: : <br /> ....... ..... <br /> BUILDING PERMIT ISSUED ................................V. . . ........... DATE <br /> ......_..................................... <br /> ADDITIONAL COMMENTS ..............................................._..-•--•-•--._..........__....------..........--••-.-----........_.. -- •........_.__..................... <br /> - ...... <br /> .... ......... ......... ---- . . ---------•--._._.........-,......._......_...._.._......_.. . .............................._.....------.._..__.._......_............ ..._ <br /> ----•--------------- -•--..... ----------- ........ <br /> .. ................ ; w <br /> Final Inspection by: --------------- ' ........ ...Date ..-. ,.- <br /> I" ' EH 13 .2h 1-68 )Lev. SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M <br />