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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT r� <br /> Permit No. �__/�� <br /> (Complete in Triplicate) <br /> .......... This Permit Expires 1 Year From Date Issued Date Issued <br /> e3 6 <br /> Application is hereby made to the San Joaquin Local Health District for a per 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 /> JOB ADDRESS/LOCATION .10'�- --------- � ,-------------------------------- <br /> -----CENSUS TRACT -------------------------- <br /> Owner's Name ---- 1Q OXY --------1_1V4-11'__S"_ 11V17I1 `tea ----------------------------Phone ------------------------------------ <br /> Address --------- /---------------------------------- --- City -- CfcT /V---------------------- ..__...._.....__ <br /> Contractor�5 Name --- --------- __________License #179 ---- Phone =_5�j _ <br /> Installation will serve: Residence ❑ Apartment House,❑ Commercial]2Trailer Court ',❑ <br /> Motel ❑Other -------------------------------------- ---- <br /> Number of living units:__'_"___-_ Number of bedrooms -------Garbage Grinder -------- Lot Size ___>4l ----________ <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 /> PACKAGE TREATMENT { ] SEPTIC TANK'[ ] Size------------------------------------------------ Liquid Depth -------------------------- <br /> Capacity <br /> ---------------- .------Capacity -------------------- Type -------------------- Material- -t- -------------- 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 _.--.---__-._____._________________-_.-...._ <br /> { R <br /> Distance to nearest: Well ________________________ Foundation ---------------------.-- Property Line -------,____-----__._____ <br /> SEEPAGE PIT [ ] Depth ---- Diameter ---------------- Number ---------------------------- Rock filled Yes ❑ No I❑ <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) ---------------------------------------------------------------------------------- ---------------------------------------------------------- <br /> ---- <br /> ------------- ----------------------------------------- <br /> Disposal Field (Specify Requirements) -----�"� OX___-.. --------- ------ - ------� -- ___-- ---- � � ``--O/T----- <br /> -------- -------------------------------------------- y / /�fir` <br /> e� <br /> « � � '� _e,�_r,6 _. <br /> / h <br /> raw e sting and required d ition o evers 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, 1 shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed ---------- ---------- - <br /> -- -- Owner <br /> BY -- -- -------------------------- ------------ ------------- Title --------------- <br /> [If other than owner) <br /> O ARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY .------ - ----- - . -_ -- - - ------------------------------- --------------------- DATE f �_".��?� - ------- <br /> BUILDING PERMIT ISSUED -------- -- ---- --------------------------------------------------------DATE -----------_----__ <br /> ADDITIONALCOMMENTS - --- --- -- ------------------------------------- ------------------------------------------------------------ - --------- <br /> ----------------------I------------------------- -------- ---`- --- ------ --- ----------------------------------------------------------------------------------------------------------------•--- <br /> ------------------------------------------- -------- -- ---------------------------------------------------------------------------------------------------------------------------- <br /> 1 <br /> / - ------ SrAI <br /> - - - ---�-- ------- -- ------ <br /> Final Inspection by: Date <br /> JOAQUIN LOCAL HEALTH DISTRICT---------------------------------- <br /> E. -- <br /> ------ <br /> -- - <br /> H. 9 1-'b$ Rev. 5M <br />