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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> ........ ........ ......... ...... Permit No. . <br /> \\ )Complete in Triplicate) 5 <br /> ( This Permit Expires i Year From Date Issued 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 Reguiationst <br /> JOB ADDRESS/LOCATION .....- ,f � •-----i.7.--,fl• .. d1Q T. _...CENSUS TRACT .......................... <br /> Owner's Name ...... l................. ' ...... .............•.........,....................,.�......:......Phone ....,......... ..................... <br /> dd <br /> Address .., �.-. �P 4?��....� AV..� T.....[ .#P...........City - i�G C. ?J. ....G. 3. 1 c�............. .. <br /> Contractor's Name ---- -�<--•/"1/- _ _ ;e _. ............................. <br /> License# . Phone 9;2 f ,fir <br /> Installation will serve: Residence P0 Apartment House❑ Commercial❑Trailer Court <br /> Motel❑Other............................................ 4 C <br /> Number 6f living units:.......... Number of bedrooms -5-....Garbage Grinder ............ Lot Size ------ ..—.•................... <br /> Water Supply: Public System and name .........................................................-----------------------------------------------------Private <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam V Clay Loam n <br /> Hardpan © Adobe❑ 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 s wer is available within 200 feet,) <br /> PACKAGE TREATMENT { j SEPTIC TANK j Size..... _6.................. Liquid Depth -.-.�` 1•••- <br /> Capacity _/� --- Type loe! !. aterial______________________ No. Compartments ...'2......;;..... <br /> Distance to nearest: Well ..... ems'.. ...............Foundation --i.......... Prop. Line . ......... <br /> LEACHING LINE { j No. of Lines -----�---------.... Length of each line.-----�-0........... Total Length .-b'5la:l.........w <br /> 'D' Box ... Type Filter Material 0.d.&6 „ p <br /> .%.De th Filter Material ............................................ <br /> 8 <br /> Distance to nearest: Well .......... Foundation -cz�'`�............. Property Line 0.............,. <br /> SEEPAGE PIT O Depth .................... Diameter ................ Number ............................ Rock Filled Yes ❑ No ❑VI <br /> Water Table Depth .................................................Rock Size ................................ <br /> Distance to nearest: Well ........................................Foundation .................... Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ............................................ Date .....,,,.......................... <br /> ) <br /> SepticTank (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 '.lam Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Hayne owner or 16e <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 became subject to ork 's Com ensation laws of California.., <br /> Signed --------- ............. Owner <br /> By -------------------------------------------- •--. ........... •--•----•----- Title ----------- -------- .......... ............................. <br /> (if other than owner) <br /> .. D ARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ,..-. ----- 2-?' ._._• <br /> -- - ------- ----------------------------------------------- ---------.... DATE .....-.�` ---... <br /> BUILDING PERMIT ISSUED __---------------- ------- ----••----- ....................... - .... .. .._.......DATE ...---------_-•----- -•--- <br /> ADDITIONALCOMMENTS -- .._--------------------------------------...._...----.•--...------ ........___-----....-.----------.-..._-.------------------------------------ <br /> ---------- <br /> ........................ _........_.. - -----:-_._. ....._.............................. <br /> .; ''�',� <br /> Final Inspection by. _...................... s .... Date _.... -.Z— ...._._. <br /> -...._............. .. <br /> EH 13 2h 1-68 Rev. 5m SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M <br />