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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> ---- ------ ------------, - Permit No. .1-1_�-/D�d <br /> (Complete in Triplicate) <br /> --------- --- ----------------_-_-------_------ ---- This Permit Expires 1 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 Regulations: <br /> ! T® � VC CENSUS TRACT ---------- 1 <br /> JOB ADDRESS/LOCATION . � ------- - ----------------------- ---------------- <br /> 3-SO <br /> Owner's Name ------ i4-IS// -------- Ei ----------------------------------------=- -------------------Phone 7-�- - -6._Z <br /> Address ( 1� 7--7�itl �} l/ - City - .�7-47cl 7_o4 ------------------------------------------ <br /> Contractor's Name -----51-4 IF---------------------------------------------------------------License # ------------------------ Phone ------------------•----------- <br /> Installation will serve: Residence T4 Apartment House�❑ Commercial �❑Trailer Court i❑ <br /> Motel ❑ Other -------------------------------------------- <br /> Number of living units:.-_-`----- Number of bedrooms --�----_--_Garbage Grinder - ---------- Lot Size _��e_X----7'�-�_-_--.. _. <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 /> 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 /> _ •��2 Oo 4-I Liquid Depth <br /> PACKAGE TREATMENT I ] SEPTIC TANK% Size-------------------- - <br /> Capacity -/�or_I Type 1,9XW___ Material__ --._.___-- No. Compartments ---------------------- (A <br /> Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line __.--_---____-_. ..._ <br /> LEACHING LINE [ ] No. of Lines th of each line---------------------------- Total Length ,___-------------_--..__ \I1 <br /> 'D' Box ----------- Type(Filter Material --------------------Depth Filter Material --------------------.-----------------.----- a <br /> Distance to nearest: Well ---------------- ------ Foundation ------------------------ Property Line -----------------•--.••- <br /> SEEPAGE PIT De th Dom' t _-_V Number _ ---------------- Rock Filled Yes ❑ No i0 <br /> [ ] p �1N rS <br /> WaterTable Depth --------------------------------------• --------Rock Size ---------------- -------------- <br /> Distance to nearest. Well ----------------------------•-----------Foundation -------------------- Prop. Line ----------......••..-- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) <br /> Septic Tank (Specify Requirements) ----- ------------------------- <br /> Disposal Field ISpecify -Requirements) --------------------------••--------------------------------------------------------------------------------------------------------- <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that 1 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. 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 bec m s ject to War l an's am n tion laws of California." <br /> Signed ---- ---------- - - -- ---t--------------- -------------- Owner <br /> ----------- -- Title --- ---- --------------------------------------------------------------- <br /> (If other than owner) , <br /> FOR DEPARTMENT USE ONLY <br /> GAJ DATEr. �� <br /> APPLICATION ACCEPTED BY .---til _____ ____f�'�__ .__ __ <br /> BUILDING PERMIT ISSUED ----------------------------------- -- ---- --------------- ----- ---------------DATE ----------------------- <br /> --------------- -- <br /> ADDITIONALCOMMENTS ------ ------------------------------------------------------------------ ------------------------------------------------------------------------------------ <br /> --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> - ----------- -------------------------I------------------------------------------------------------------------------------------------------------ <br /> ------------------------------------------------ -------=------- <br /> � D _Final Inspection by C --------------------------------- --------•--------- Date --- <br /> C <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'S8 Rev. 5M <br /> r <br />