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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> ................... Permit No. <br /> (Complete in Triplicate) <br />....................................................... ,��'� 3. . <br /> _.................................... This Permit Expires ] Year From Data 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 mode in compliance with Count Ordinance No. 549 and existing Rules and Regulations: <br /> z� i2e <br /> JOB ADDRESS/LOCATION .... ................. CENSUS TRACT .......................... <br /> ryf ........=•.............:. :.........Phone(?W:7.". ^lOwner's Name ........ ` .... �. <br /> Address ................... ....._...... ...... City <br /> Contractor's Name .................... .. ._ --• -_-. .�v�'�J----.•-:••--•-..License # .� zj Phone <br /> Installation will serve: Residence Apartment House 0 Commercial'[3Traller Court 'Q <br /> Motel E]Other ............................................ <br /> Number of living units:......�_... Number of bedrooms .......Garbage Grinder ...._ of Size ..ckZx _�.................. <br /> Water Supply: Public System and name .................................................................... IF------------. ---.._..... .......Private ❑ N4 <br /> "Character of soil to a depth of 3 feet ""'Soni Q'"""Silt[3 '°Clay"❑ Peat Q —Sandy-Loam C] Clay Loam Q <br /> Hardpan ❑ Adobe)K Fill Material ............ If yes,type .............. <br /> (Piot 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 TAMC'[ ] . Size................................................ Liquid Depth .......................... <br /> Capacity ------_------__ 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 ...._......_............. .................. <br /> Disiance to nearest: Well .....................•.- Foundation _..__.... .............. Property Line --------................ <br /> SEEPAGE PIT Depth .. ❑ I] <br /> O p .................... Diameter ----._._.._.:... Number .................._.... ... Rock Filled Yes No <br /> • Water Table Depth .Rock Size <br /> Distance to nearest: Well ........................................Foundation ....___......... Prop. Line ..... ................ <br /> f <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ----......... .:_..___•..................... Date .......................----------- <br /> Septic <br /> ---_.Septic Tank (Specify Requirements) --------- ----------... ..........................................................................--••--•---•- <br /> Disposol Field (Specify Requirements) ....... , r G .. .....................•-•--------•------------ <br /> ............. ..----•---• �f.._x.. . x �� R. --------- <br /> •----. ----•...............................•---..._...••••----------._...----•----...__................_. <br /> (Draw 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 i <br /> as to became subject to Workman's Compensation laws of California." <br /> Signed ------------------------ - ----- ...................................... Owner <br /> By -------------- - . ...................................... Title � ................... <br /> (If other, t an owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATIONACCEPTED BY........................................... •...................... ........._....__.............. DATE .......................................... <br /> BUILDINGPERMIT ISSUED .........................................:..................................I..............................DATE ...................... •---•-------•- <br /> ADDITIONALCOMMENTS ............................................................................................ ............_._..------------------------------.._............. <br /> --•----------•-•-••---.........i........•......................................•---..._..................,....... <br /> .................................... <br /> .......... <br /> ................. <br /> .._........_......................__.... ..........--....... <br /> Final Inspection by <br /> --------------- 7 ::....Date __.. . :7 ------............... <br /> SAN JOAQUIN LOCAL HEALTH ISTRICT <br /> e u <br /> 13 24 ti •moo o_.. ua 7172 3-M <br />