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. FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> IComplete in Triplicate) PermitNo. .. .................. <br /> ....................................... <br /> ......... This Permit Expires 1 Year From Dot*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 /> E , <br /> JOB ADDRESS/LOCATION ...... ... �. ._. _. .......... --.------ .............................j . �'............C1:NSUS TRACT .......................... <br /> Owner's Name -------- _ .... --..tet `. _....:................................................ ..Phone .................................. <br /> :. <br /> Address .n. 0 r . City .............. <br /> Contractor's Name ----------- . ..............................................................•- License # :.._....:..... .......... ....................... <br /> Installation will serve: Residence Apartment House(] Commercial QTraller Courts 0`T <br /> Motel ❑Other .............................E.- <br /> Number of living units:.... Number of bedrooms :......Garbage Grinder ..f........ Lot Size'.:'.... . ....a-44 _.. --_ <br /> Water Supply: Public System and name ..................... -•-•-•---...._.....--•---........._---••-•---••---•--•.......:.........................Private ❑ <br /> Character of sail to a depth of S feet: Sand* Silt Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> . <br /> Hardpan I] Adobe fl Fill Materia! ............ 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 a liable within 200,feet,) <br /> PACKAGE TREATMENT ( ] SEPTIC TAMC j Size_..._L4. a.... ............._...._ Liquid Depth .......................... <br /> Capacity -- rf.�r__-- _ Y`pe ---n Material--.--.................. No. Compartments .... <br /> Distance to nearest: Well --------5.Q----------------•....Foundation .l��-1.•.._.._....... Prop. Line __-.2_Q.._.----. <br /> LEACHING LINE ( j No. of Lines __.3______________ Length of each line. -3--------4,�PTotal Length <br /> 'D' Sox ..J....... Type Filter Material ............ .......Depth .Filter Material ....................................... <br /> Distance to nearest: Well ........................ Foundation .......... Property Line ........................,� <br /> SEEPAGE PIT { j Depth ____________________ Diameter ---_.---_-_-__ Number ............................ Rock Filled Yes Q No �� <br /> Water Table Depth ---------------- ----------•----- ... ..........Rock Size ................................ <br /> Distance to nearest: Well ............................•-..........Foundation ----.-:.__- ........ Prop. Line ............. <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ...:........................................ Date ..........._ ..................... 6 <br /> Septic Tank (Specify Requirements) ----- ----------------•--•--....................................._.-..-........... - ........................................I........ <br /> 1 <br /> DisposalField (Specify Requirements) -------------------------------------•- ---------------------------------------------------- ••----.... ......................... <br /> I <br /> .......... ---------------•--••--- ----------------­---- -----•----..__._.....................................................................................................•........................ <br /> ----------- ..........----------------------------------........................................................... <br /> (Draw existing and required addition on reverse side) <br /> 1 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- <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 sub'ect to Wor an's Compensation laws of California." <br /> Signed 3 f?-I -- - ---------------------------•---._.... Owner i <br /> By -'---'-----'----'----'- --------------------------- xl i- ---------------------------------------------- Title -. ....-' ..................... ........................ <br /> ..-.....'r ' <br /> (if other than owner)- , <br /> FOR DEPARTMENT 'USE ONLY <br /> APPLICATION ACCEPTED BY - " DATE <br /> BUILDINGPERMIT ISSUED ------------------ -- -• --- --••------...--...-•-------------------,.-_------ .......---DATE ........................................... <br /> ADDITIONAL COMMENTS '-' ------ ----- ---------•----------•----• .... - <br /> •--'-'----•-------------- —---------------- -------•-------- ...-..-----------------------------------------•-- <br /> Final Inspection by: _.__. ._ Date ...... .'.�U..�"15........_.. <br /> Ell 13 2!t 1-6$ 5M SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M <br /> J1 <br />