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FOR oFl+lcE USE: APPLICATION FOR SANITATION PERMIT <br /> - lr' Permit No7 - - <br /> (Complete in Triplicate) <br /> This Permit Expires i Year From Date Issued <br /> Date Issued/d. -_D- 7d <br /> ----------------------------------------- <br /> -----------__--- <br /> Application is hereby made to the San Joaquin Lo al Health District for a permit to construct and install the work herein <br /> described. This application is made'in complian a with County Ordinance No. 549 and existing Rules and Regulations: <br /> �f p 4 y <br /> JOB ADDRESS/LOCATION 7nf6�r`-�1.} -�.-- ------------- --- ------ ------------ --------------------------CENSUS TRACT -------------- ---3--•.._. ' <br /> Owner's Name --------�-- --------- <br /> C ' ------------------------------ ----------------------------------- ® � )Phone y-IYO- _..__ <br /> Address ------ ------------ } --- <br /> - V ----- - ---------- --- -------•--- City - ae -- ------------------------------------------------ <br /> -k Name -__-lti�--____ __" _ t�--- --- -=--------License #fw __---_ Phone ' � f f <br /> Installation will serve: Res idence;?�Apartment House,❑ Commercial:❑Trailer Court i❑ <br /> Motel ❑Other -------------------------------------------- <br /> Number of living units:1____ Number of bedrooms ------Garbage.Grinder ---------:;77, Lot Sze <br /> ------------------------------ ---------- <br /> Water Supply: Public System and name ----------------------------------------------------------------------------------------------------•---------Private <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt C] Clay ❑ Peat❑ Sandy Loam -❑ Clay Loam ❑ s <br /> Hardpan ❑ Aclobe1g. Fill Material ____________ If yes,type ---------.________________ <br /> (PI'ot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) t <br /> NEW INSTALLATION: {No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] 47X/,IT� ---- Liquid Depth --------------------------- <br /> Capacity - ------------------ Type -------------------- Material---------------------- No. Compartments -------____----- <br /> Distance to nWst: Well -------------•----------------------Foundation ---------------------- Prop. Line .--------------_-_---- <br /> LEACH1NG LINE [ ] No. of Lines _�-- /VVength of each line-__________________________ Total Length <br /> 'D' Box _______-.___ Type Filter Material ____________________Depth Filter Material --------------------------------------- <br /> Distance <br /> ____.__-___--_Distance to nearest: Well ------------------------- Foundation _______________________ Property Line ______--__________---_ o <br /> Number ___________________________ Rock Filled Yes ❑ No i❑ R <br /> SEEPAGE PIT [ ] Depth ____:�____________ Diameter ___________ __ VV] <br /> S \ <br /> Water Table Depth ------------------------------------__--------Rock Size -------------------------------- <br /> Distance to)nearest.. Well ----------------------------------------Foundation ---- ------------- Prop. Line ---------------------- <br /> REPAIR/ADDITION(Prev. Sanitation;Permit# ---------------------------------------- --- Date ___________________--------------) <br /> SepticTank (Specify Requirements) ---------------—--------------------------- ---------------------------------a------ -----------------------.-------------------------- <br /> Disp sal Field (Specify Requirements) _ 5 / ____fet_ _- eat' - �"r�< ----VL- - -- <br /> 47 -- ---------------------------------�? --- ------- -------------------------------------------------=------------------------- - ------ <br /> (Dra 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- <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 be me subject to orkm 's Compens n laws of California." <br /> Signed �J <br /> �_ ° <br /> -------_____________-----_.____.____-_____ <br /> BY --- - - -- ------- ---------- Title <br /> (If other than owner) <br /> FO DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ------1 --------- ---- ------------------ ------------------------I--------- DATE .-. -------------- <br /> BUILDINGPERMIT ISSUED -------------------------- -------------------------------- -------------------------------------------DATE - ------------------------------ ---------- <br /> ADDITIONALCOMMENTS ---------------------------------------------------•----------------------------------- -------------------------------------------------------- ------------- <br /> ------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------- <br /> =------------ --- ------------------------------------------------------ = <br /> Final Inspection by: _.__ _ _ V-4 ----------------------------------- ate <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'bl3 Rev. 5M <br />