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3 <br /> FOR OFFICE USE: <br /> .�� APPLICATION FOR SANITATION PERMIT 7 <br /> -------------- - -------------��-------- ----- y f Permit No. -(--�---f��--�.,-. <br /> (Complete in Triplicate) <br /> --------- -------------------- Z Z 7 <br /> 4, Date Issued <br /> ---------_----_--_---------------------"-_-_--------_ This Permit Expires 1 Year From 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 Mules and Regulations: <br /> L, -----•-- -------- <br /> JOB ADDRESS/LOCATION .---y��%o�- -- ---��� �'j---------- -------------- - ---------- •-----CENSUS TRACT ----------------- -------- <br /> Owners € -- ------------------------------------------------------------------- -Phone -......' Q� <br /> syr y.� City <br /> Addres -----•---------------------------------------------- - --- --------------------------------- <br /> Contractor's Name -------------------------------------------------------------------------------=------.License # -------------- --------- Phone <br /> Installation will serve: Residence ®-Apartment House❑ Commercial ❑Trailer Court ,❑ <br /> Motel ❑ Other -------------------------------------------- <br /> > <br /> Number of living units:_.-I------- Number of bedrooms _,3-------Garbage Grinder ------------ Lot Size ____-_________ <br /> Water Supply: Public System and name --------------------------------------------------------------------------------------------- --------------.-Private K-- <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam .❑ Clay Loam.� <br /> t <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 sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK![ ] Size------------------------------------------ --- Liquid Depth ------------------- ------ <br /> Capacity -------- -------•-- Type ------------- ------ Material----------- ----------- No. Compartments ------ ---------- N <br /> Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ---------- -.. _ <br /> LEACHING LINE [ ] No. of Lines _____:__________________ Length of each line---------------------------- Total Length ---________-----______.._.-- <br /> 'D' Box .----------- Type Filter Material --------------------Depth.filter Material -----------------------__--------_------- <br /> c <br /> Distance to nearest: Well ------------------------ Foundation ------------------------- Property Line _-______-_-._..__._.._. <br /> ___ Number ______--------------------- Rock Filled Yes No <br /> SEEPAGE PIT [ � Depth -------------------- Diameter ------____-- ❑ ❑ <br /> WaterTable Depth ------------------------------------------------Rock Size -------------------------------- <br /> Distance to nearest: Well ----------------------------------------Foundation----------- ---------- Prop. Line -------------- ...... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# --- ---------------------------------------- Date ____________-...________....____-} <br /> SepticTank (Specify Requirements) -------- ------------------------------------------------------------------------------------------------- -------------------------­ <br /> Disposal <br /> -------------s---------•--Dis osal Fieldrcjfy Requirements) Q -"��-�!� <br /> a a --�== `-------- --- ---- - -- 2 /J / -------- <br /> . <br /> r - ----- /� <br /> {Draw existing a ¢quire�addition on reverse side <br /> F d- hereb�i rt fY t at 1TateLaws, <br /> prepared this application and that the work will be done in accordance with Son Joaquin <br /> ���[[[[ County Ordinances, and Rules and Regulations of the San Joaquin Local Health District. 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 su je to Workman's Compensation laws of California." <br /> Signed ._� __ ____ <br /> --- -- --------------------------------------------Owner <br /> BY --------------- ------------------------------------- -------------- --- Title ---------- ---------------------------------------------------- <br /> (lf other than owner) <br /> I EPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ----------- ------------------------------------------------------------ DATE --- J29` --------------------- <br /> BUILDING PERMIT ISSUED - --- - ----------- ----------------------------------------------------------------DATE ---------- ._---------- --------------- <br /> ADDITIONALCOMMENTS ------------------- ------------- ----------------------------------------------------------- ------------------------------------ <br /> - - ------ -- - -------------------------------------------------------------------------------------- <br /> Final Inspection by: -----:r ----------------------------------------------------------------------Date <br /> ". _� " <br /> AN JAQUIN LOCAL HEALTH DISTRICT <br /> ,= E. H. 9 1-'6$ Rev. <br />