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--f•OR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ....................................... <br /> (Complete in Triplfcatel Permit No. <br /> .............................................. _ <br /> This Permit Expires 3 Year from Date issued Date ssued ....__ ..�...._... <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 Regulationsr � <br /> JOB ADDRESS LOCATION /! _/.'*......... <br /> CENSUS TRACT _.._ ... <br /> Owner's Name- �.:/ � =�..T ............................... ..'. Phone <br /> C7' <br /> Address . .•-_� ' Gam... ................................................. <br /> f" City - <br /> I , <br /> Contractor's Name ------------ . !_ -------.License # ------------------------ Phone ......-..........._....... <br /> .... <br /> Installation will serve: Residence fe Apartment House❑ Commercial❑Trailer Court <br /> e <br /> Motel❑Other-------------------------------------------- <br /> Number of living units:_.. __----- Number of bedroomsGarbo e Grinder _,_.._ g __-__----.- Lot Size ------------------------ ........ <br /> Water Supply: Public System and name ----------------------- .................................____............... .......=..................Private,M <br /> Character of soil to a depth of 3 feet: Sand t] Silt❑ Clay ❑ feat❑ Sandy Loam V Clay Loam <br /> Hardpan[] Adobe,Q Fill Materiol ........ If yes,type .........6... .. <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 IJ `" Size......................................... ..:. Liquid Depth _.-----------•............ <br /> Com <br /> Capacity ---------- -•-•----- Type -----------•----- Material...................... No. Compartments <br /> ......................� <br /> Distance to ne rest:. Well -_------------------•-•- ----•--•--Foundation ----------_----------- Prop. line ...................... <br /> 't: i <br /> LEACHING LINE ( ] No. of Lines ---------------- .^----.Length of each line --.-........... ;Total Lengthy"........................... <br /> S <br /> I. D' Box ............ Type Filter Material --------_------ Depth .Filter Material ............................................ <br /> 4 Distance to nearest: Well -------------------:'7 Foundation ------------ .._.. . Property Line .:_...._.. .............. <br /> s <br /> SEEPAGE PIT ( i Depth ____________ _______ Diameter, ----------- Number ---- _ t � Rock Filled-' Yes ❑ No �❑ <br /> 3 Water-Table-Depth ................................................Rock Size _..---- ..-----------•. <br /> t <br /> Distance to nearest: Well ---------------------- --.._.--Foundation ---f...... <br /> -_.....___ Prop. Lime ............ <br /> t <br /> REPAIR/ADDITION(Prev. Sanitation Permir# ....._•--- ------- Date _.___..__.._ ------•-- --------- <br /> l <br /> Septic Tank (Specify Requirements) ................. ....:.. �..--?r.......................................... ........................._.. <br /> w� �, .._ a .�. <br /> Disposal Field (Specify .Requirements) ��i.���`,f_.��{� � <br /> ____-._. . -�._.__ <br /> ! F J d' <br /> ----------- <br /> -----------_____________________ ____ .___-._..__________________ -_-...____._____ - ..--.._- ------------------ __-_--...._____.------•__-__________---..________- <br /> t ' (Draw existing and required addition on,reverse side) F <br /> 1 hereby certify that I have prepared this application and that the work will be done in' accordance with San Joaquin �. <br /> l County Ordinances, State laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- <br /> sed agents signature testifies the following: ; ��•�.��T* <br /> "I certify that in the performance of the work for which this-permit is-iirsued, I shat[ not employ any person in such manner <br /> as to 6ecoine subie o kms Compensation lawn of California':", <br /> Signed ----- . ---- ' Owner' <br /> . - <br /> BY •------------------------------ -- ------------- - ------ Title --- - �. <br /> (If other than owner) <br /> R EPARTMENT USE ONLY"�. <br /> F <br /> APPLICATION ACCEPTED 8Y ". DATE <br /> BUILDINGPERMIT ISSUED .-..._.._-- `-------------•----...----------------------------------•-----------------------------•- ---DATE _..- ------- ........ ------'---- <br /> ADDITIONAL COMMENTS .--------- --•--- <br /> Y <br /> ________________________________•--.-..._..__________..__..-______-___.-......_....._._..__._.______.._...__.....__......_._____..._..,-..............-.......-..-__.._. ..__............................. <br /> 4 ._.._ _ -s_____________________________________ ___ _ <br /> Final .Ins ection b .. . �� . ------- ---J---------- <br />` p Y Date . .._..... <br /> EH 3 24 1-68 Rev. 5mSAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M <br /> r <br />