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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT �d <br /> ....+_�.................... Permit No. . _....__.._../... <br /> ► ry �!� (Complete in Triplicate) <br /> I"r '� Date Issued <br /> ................... .......................... This Permit Expires I Year.From 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 /> i <br /> ten- _. <br /> JOB ADDRESS/LOCAT N . Q k .............................................CENSUS TRACT ........._.-.............. <br /> Owner's Name .. ......... ..... !? t�t.�f?.. ......Phone .. :�6 .......... <br /> ......... ...................:............... <br /> .QQ � 3 <br /> Address ................0..�' _ ._._ ....... - zt!�..r... --j ._. City .. .......................................... <br /> X66_ <br /> Contractor's Namer�� �f__. '__ h't/1..........................License'# ..3 ., .... Phone .. <br /> Installation will serve: Residence t%A.partment House C❑ Commercial []Trailer Court 0 <br /> Motel 0 Other ..44� 1 7 r t --•- <br /> ....... <br /> Number of living units:.._ —....—Number_of-bedrooms,._ . <br /> �....Garbnge Grinder.._._.. Lot Size ?7 ._.. _.. ..l ...... ..............._ <br /> Water Supply:.Public System and+name ....•_____ .......... ....._._.._....... --.- .n -. ............_]_Private ❑ <br /> Character of soil to cl pm of 3-feet:-�'Sand o' tilt❑ Clay ❑ Pegt❑ Sandy Loam fl Cloy Loam <br /> �- �- <br /> Hardpan ❑ Adobe Fill Mtiteriai ---------_._ If yes,type ---•------•----._.....-•---- <br /> (Plot plan, showing size of lot, location=of system-in relation to wells, buildings etc. must be placed 'on <br /> n reverse side.) ' <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted If ublic sewer is:available within 200 feet,) <br /> PACKAGE TREATMENT [ } >TIC TANK I ) LSize._.:-- ..::•�` ­--------- - L q id Depth ------------•---- <br /> ----•-•-- <br /> Capacity__------•---_-- Type ................ j.►s e .......I....... No Compartments ......................� <br /> Distance to nearest:._Well _____________A!�.....,.-,.........Foundatlton ...................... Prop. Line ______••___-_ ........ <br /> LEACHING LINE [ ] No. of Lines ________________________ Length of each line-------------............... Total Length <br /> YP _Depth Filter Material __--.--...._..... <br /> D' Box Type Filter Material ....................... <br /> _.. 1 ' <br /> Distance to nearest. Well _.A_ Foundation - "�'`. t ......... Property Line .......:................ <br /> SEEPAGE 'PIT Depth ..............:. ' . . t <br /> O p ._._ Diameter ________________ ..........t._........ Rock Filled 'Yes ❑ No 0 , <br /> Water Table Depth ................................................Rack Size:-... ............................ <br /> Distance to nearest: Well I <br /> • -----------•............................Foundation ------•----------•-- Prop. Lina .........------------ <br /> REPAIR/ADDITION(Prev. Sanitation Permit ............................................ Date -.-•_-- .......................... . <br /> 1 , <br /> Septic Tank (Specify Requirements) ....................-.... ....__..__._.._..-__._----- -------------------------------------------------- <br /> ------------------•------ -------------------- -------------------------- <br /> Disposal Field (Specify Requirements) ----- -_-.-- _ __--- -_-- ..............------------- <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�wiil}bei done in accordance with San Joaquin <br /> County Ordinances,I Slate Laws, and Rules and:Regulations of the San Joaquin Local Health DliMc'l 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 subject to Workman's Compensation laws of California." <br /> Signed <br /> .................... ............ Owner <br /> .•• -------•-_.... <br /> 1 <br /> By ........... ...... ........ ....................... - Zitle'"_.. ._ %_ . ... ............................ <br /> (If a r than owner) <br /> FOR DEPARTMENT USE ONLY <br /> 40 <br /> APPLICATION ACCEPTED BY ..-- !-r -. ------------------------------- ----.... DATE .._..�I�"_�Q.`Z ----.._._....- <br /> BUILDING PERMIT ISSUED .......DATE ' <br /> ..z.......- <br /> ADDITIONAL COMMENTS .......... .............. <br /> �1 ............................t ............................................................._._....... .... <br /> ................... ......___....._• --------------- .�.-F. ....... - ._......._............._.............,-.__...._....................------- V <br /> '....................... ......•------- - - , <br /> Final Inspection .._..•Date .......... ............. <br /> SAN .JOAQUIN,LOCAL HEALTH DISTRICT <br /> r ,. <br /> 1R 74 , <br />