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tUR OFFICE USE- <br /> APPLICATION FOR SANITATION PERMIT <br /> 1Completo In Triplicate) Permit No. ._.7s. ......... <br /> ................;._....................................... This Permit Expires ] Year From Dot*Issued <br /> 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 /> r � /J <br /> JOB, ADDRESS/LO ON .Al <br /> (.!r_.. 24� <br /> ...... .........•- ••................. ......................................CENSUS TRACT <br /> Owner's Nome . .. ...... ... . ....•-••� one .......................... <br /> -- -- ----- -•-•. .............. Ph <br /> Address `��.�- - <br /> ..- --- ------------. .....-... <br /> City.... .. - .... <br /> Contractor's Name __-.:. .........................License #/.t� ✓� ... Phone .............................. <br /> installation will serve- Residence[Apartment House f] Commercial ❑Trailer Court <br /> Motel ❑Other ......•....................................... <br /> Number of living units:..__.(•--- Number of bedrooms ._._ _Garbage Grinder <br /> ............ Lot Size ..�... _.. . ._. <br /> ......... <br /> Water Supply: Public System and name --------------- ....Private <br /> Chart Iter of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam Cloy Loam ❑ <br /> 4 <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 /> PAC <br /> ICAGE TREATMENT [ ] SEPTIC TANK f ] Size—........ ........ .... -. ----.... Liquid Depth .......................... <br /> r <br /> Capacity <br /> } ..-----• -- Type -_-•----------_-- Material......._------------- No. Compartments .................... <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 ...........................................m <br /> Distance to nearest: Well ........................ Foundation --.-.-----•--. ------_- Property Line ....._._...... ......... <br /> SEEPAGE PIT [ } Depth _.....- ----------- Diameter ................ Number --------------------•.------ Rock Filled Yes ❑ No ❑-Q <br /> Water Table Depth ---------------.................................Rock Size ................................ <br /> Distance to nearest: Well ........................................Foundation .................... Prop. Line ...................... <br /> . <br /> REPAI?/ADDITION(Prev. Sanitation Permit a# -------------------------------------------- Date ......-...................,------- <br /> } <br /> Septic Tank (Specify Requirements) ............. ...................................................... <br /> ......... - _..... <br /> Disposal Field (Specify Requirements} -_----------_------------_..-.......r <br /> (Draw existing and require 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 /> Count Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or Iiren- <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"come subject to Workman's Compensation laws of California." <br /> ----------•-•• -------- Owner <br /> By <br /> Signed <br /> g -- _ <br /> 4 ... , xitle r - - 11+x. <br /> ----------------- <br /> (if other than owner( <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY _. .... .. .. . ..... .----------- ....,... DATE _ ... .. <br /> BUILDING PERMIT ISSUED ------------ --- <br /> ----------- - ---------------------------­- ...........---DATE - ._.. ----------------------- <br /> ADDITIONAL COMME=NTS ..........._­.­--------- <br /> ---------------------------------------------------------*..........*--------- <br /> -------------- ••---------------------- --..._...---..---•----- -------------------- <br /> .----------- <br /> ----------------- <br /> Fina Inspection b . .................Date ...._... <br /> EH <br /> 13: 2L 1`68 SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M <br />