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FOR OFFICE USE.. <br /> _t�........�A.../��3 6 APPLICATION FOR SANITATION PERMIT <br /> ----- .............. 1 <br /> lCompleto in Yr-Oleato P ------------------ <br /> N6. <br /> ................... _0_ <br /> .......I................................ 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 heroin <br /> described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> 7 (0JOB ADDRESS/LOCATION ............. .......... ......... ............................CENSUS TRACT .......... <br /> Owner's Name ........ ... ------------- p ................. ......I............. .....................Phone .................................... <br /> Address ............ .... ............ <br /> .......... ......... ............ <br /> ------------ .............. <br /> Contractor's Nome ..........._jZ1Q.'_ .... ..License ... Phono7-�. <br /> Installation will serve: Residence aAfartment Housefl Commercial OTraller Court 0 <br /> .living un Motel fn Other........................................•-•- <br /> Number of <br /> its:-.-. ... Number of bedro s rbagp f7rinder e-.j*.... Lot Size _6..0 .... .......... ........ <br /> N <br /> Water Supply: Public System and name ............... <br /> ........I....... ....---.............................Private <br /> Character of soil toa depth of 3 feet: Sand Silt(:] Clay Peato Sandy Loam {:l Clay Loam E] <br /> Hardpan 0 Adobe ET Fill M6terlal ..A/A. If yes,type............... . .......... <br /> (Plot pion, 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 I I Size.......................................I........ Liquid Depth �........................ <br /> Capacity ---_--------- ..... Type ... ----_-----_-- Material---------------------- No. Compartments ...................... <br /> Distance.to nearest: Well ....................................Foundation ............. ........ Prop. Line ...................... <br /> LEACHING LINE No. of Lines __- ---------------- Length of each line_........._......._......... Total Length ...._1....•........ <br /> V Box ............ Type Filter Material ....................Depth Filter Materi6l ............................................ <br /> Distance to nearest: Well ........................ Foundation ........................ Property Line .... ............ <br /> SEEPAGE PIT, Depth _---_----------- Diameter ................ Number ---------------- ........... Rock Filled Yes C] No C3 <br /> Water Table Depth ........ ----------------_------_- .__....----Rock Size ................................ <br /> Distance to nearest: Well ........._....... .....................Foundation -------------------- Prop. Line ....................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ----------- -------------------------------- Date .._..._...................._......I <br /> Septic Tank (Specify Requirements) --- ........ ....... ......... ... ................................... ...... <br /> Disposal field JSpecify Requirements) --------- ........................... <br /> ;� .......... ---- --- <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 Son Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the Son Joaquin Local Health,District. Nome 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." <br /> Signed --------- - -- -------- -------- ----- ---- --- ------------------------ ---- Owner <br /> By ..... -------- <br /> ----------- Title <br /> other than�b erl <br /> f <br /> FOR Dh PARTMENT USE ONLY <br /> APPLICATION ACCEPTED By _ _� - ------ ....�. DAT�E* <br /> BUILDINGPERMIT ISSUED ................................... -------------------------------------------------- ...................DATE .-_---_----------------- ............... <br /> ADDITIONAL COMMENTS ................... ....... .............. <br /> ---------------------------------- -- -- --------- ­----------- ................ ----------------­-- ............................... --------------------------------------- <br /> --------------------------- .. .... . ........... .. ---------------------_----- --------­---------------I.. ........­­...................1-1................................... <br /> ---F ---- - - ------- ----- ---- <br /> inal-Ins-p-e-ction-by:------------ ----- ------------------------ ------------------------------------------------- ............. <br /> EH13 2h 1-68 .................................... ......................................Dote ......... .... .U'----7 .......... <br /> SAN OAOUIN LOCAL HEALTH DISTRICT 8/7h 3M <br />