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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br />.....,....-...................................... ..--__ Permit No. .. ....... .l <br /> {Complete in Triplicate) <br />_....._.... ................... .. a 75 <br />•.••••.•--.-•....................... .............. This Permit Expires 1 Year From Date Issued <br /> Date Issued ..Q?.:............. <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. 5.44 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION . -. _...-.. _._�_.!l-lY..__.�. 4 .e'.� <br /> .-...................CENSUS TRACT ._.._.-..---._..... ...... <br /> Owner's Name ........ � s4 Y �' Phone <br /> Address ------------- f?? _....... --- ---........_..._....-•••-•...... .-•--•--•------.... City _.- 'f. _G_OtV..._-....._..... ..-........_-....-----•.._. ._ <br /> Contractor's Name ._ � .! l'f7.b 'f ... ........................License #,006."_171'?*c..... Phone ��x .'y ' .. <br /> Installation will serve: Residence JN Apartment House❑ Commercial ❑Trailer Court C] <br /> Motel ❑Other ............... -------------•-----•-- <br /> Number of living units:....../... Number of bedrooms __3------Garbage Grinder ............ Lot Size .....4&rA......................... <br /> Water Supply: Public System and name ..__-----•••-••-•---•---------••-•--.-.----------•..........................•-------------•-•--•--•............Private <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ -Clay ❑ Peat❑ Sandy Loam [] Clay Loam ❑ <br /> Hardpon,o Adobe❑ Fill Material ............ If yes, type ___________________________ <br /> IPlot plan, showing size of lot, location ofsystem in relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: JNo septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT f ] SEPTIC TANK ] Size... Y �fX `f <br /> -----------•._..------•_.... Liquid Depth _.._...-r--•-•----•-•------ <br /> Capacity ......... Type Material. C..... No. Compartments ......................w <br /> Distance to nearest: Well �� --Foundation 3�� <br /> --..._--•-_. Prop. line . ............ <br /> LEACHING LINE [ ] No. of Lines -----..'�............. Length of eachf__..___-__-... Total Length / ............t}► <br /> V Box ..-./------ Type Filter Material .444A..Depth Filter Material ._?c7... ........................... <br /> :... <br /> Distance to nearest: Well ._/!S ' Foundation ............ Property Line ....�.... N <br /> SEEPAGE PIT Depth 1-P,�' :____. Diameter Number ._._•_____ ________ ..... Rack Filled Yes`E No 0G <br /> Water Table Depth ............................................Rock Size 9 <br /> Distance to nearest: Well ........................................Foundation .................... Prop. Line ...................... <br /> REPAIR/ADDITION IPrev. Sanitation Permit# ..-......................................... Date ---.---...........................) <br /> Septic Tank (Specify Requirements) _........ .................... j <br /> Disposal Field (Specify Requirements) ----------------------------------------------•--------•------------------••--------_ ------------•-•---•--- -----� <br /> -••--------------------------------------••-•-------------------------------•_..._....•--••••------------------------------------------------••-------- --•----------------------------------------- <br /> 1--................................................. __ -------•---•- --- ------_..-----.._-.-.....------••-------...._...._.__..__ <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, State Laws, and Rules and Regulations of the San Joaquin local Health District. Home owner or licen- t <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 ploy any person in such manner <br /> as to become subject to Workman's Compensation laws of California." , <br /> Signed -.. �_-/�Nfr �! ` ...SN............. Owner <br /> By .......V.. . -_.. - ........ •- ......--.............................---........... .Title ..... .......-.................................................. <br /> ......, <br /> (If other t a owner) <br /> _ FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED 13Y .--•.... Fi'� ...._ . . .................................•-•-------- ......... DATE `..Z.:S_....-......... <br /> BUILDINGPERMIT ISSUED ............................ --••••-•.......-------•---------•----.------•-----•--._...----_._.._......_..DATE ........................................... <br /> ADDITIONALCOMMENTS .....................•--•----•-.....•••••••••--•.........----...------•---••-----•. ..................... <br /> ........................................--••••-••••--•-------...........-i••-------------•-•-----.....---•...__....................-•--•--•-------.__._.-----•-•--•--••---.........................._..... <br /> --•------------- ---------------•---•.......--..-.... .__ - <br /> Final Inspection by: �%..._.... :.. .. .. <br /> ...............................................................Date .. ..: ....... <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br />