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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> Permit <br /> ....................................................._ _ (Complete In Triplicate) _ _:......M ...:. ..,:.:.. ....::,. :.... ,- � <br /> :..............................I........................._ Date Issued .. '.. <br /> This Permit Expires t Year From Date Issued <br /> ....................I........................... <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 Regulations: <br /> i. . . . <br /> JOB ADDRESS/LOCATION r -_ d ` -. CENSUS TRACT <br /> ,ems Gly. .. lx-vet. .. ..........:.......:................Phone ... ............... <br /> Owner's Nam ............. -six <br /> -•................ City .. <br /> Address �-•- r ------------ ..... - --...-�. ��� Phone .....:........... .... <br /> 4?�'..License # ..t,�, <br /> .. <br /> Contractor's Name .. .... . ....... ..... .... <br /> Installation will serve: Residence Apartment House Commercial QTrailer Court Q <br /> MotelQ Other.................•.......................... <br /> Number of living units...-. Number of bedrooms ..Y._:Garbage Grinder .Lot Size ......................... .11 <br /> Water Supply: Public System and name _. ........ <br /> -•...:......... . ... ....:. . __�r_l�a.^-��.. ... ....:.....::Private Q <br /> Character of soil to a depth of 3 feet: Sand b Slit Q -Clay ❑ Peat Q Sandy Loam Clay Loam Q <br /> Hardpan p Adobe Q 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 /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available.within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK Size..................... .... .... <br /> . <br /> .. <br /> ..... Liquid Depth .---•:.:.. <br /> Capacity Type ---_,..,_Material....................... No. Compartments ........:.:......... <br /> i Distance.to nearest Well ........-Foundation ..... ..,i'rop. Llne --•................... <br /> . <br /> _~_ Length of each line............................. Total Length ................:.. ...... <br /> LEACHING LINE [ �. No. of Lines •�------------------ 9 ,.. <br /> 'D' Box --- _...:. Type filter Material ....................Depth Filter Material ................................ ....... <br /> Foundation ....... Property Line ................ <br /> Distance to nearest: Well ................. Foundation .......-----..... ...:... <br /> SEEPAGE PIT [ Depth -------------------- Diameter ................ Number ..................... Rock Fillet! Yes Q No C1, <br /> Water Table Depth ------ ..--- -_--•----Rock Size ............. - :.:.......... . <br /> Distance to nearest: Well ............................. <br /> =--Foundation Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit ` .......................... Date ---:•------ ............ = <br /> Septic Tank (Specify Requirements) ..............................................'...------.............--- ....----••......--•-- •..,�.. ...... ......... <br /> Disposal Field (Specify Requirements) __- .................. ....... . . ------•--.......... <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, Stale Laws, and Rules and Regulations of the Scan Joaquin Local Health,Distrlct. 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 to Workman's pensation laws of California." <br /> Signed -----•--- -•- ---.-. -----•-------------- --•-•- ----------- _.... . ----- • Owner <br /> l , --(f_ . --^-_- <br /> -:-. title <br /> .. <br /> (if other than owner! <br /> FOR DEPARTMENT USE ONLY J <br /> _ - p� <br /> �-2c......... <br /> APPLICATION ACCEPTEDr BY ------ . - ................................ ------------ DATE.--•© •`2.-._ <br /> BUILDING PERMIT ISSUED ---------------- ------ .........DAT ...--------------------................... <br /> ADDITIONAL COMMENTS ..------•-•---••--- .---------•--•---------------- <br /> ----- -- ------------------------•---•-•-------•--------....---------•------------•-•--........---------.-.....----..-..-.................--•- <br /> ..... <br /> Final Inspection by: <br /> _ . .Date -- - - •......................_......------ <br /> EH 13 24 1--68 11ev. 5H SAN JOAQUIN LOCAL HEALTH DISTRICT 8/74 3M <br />