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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT 4✓ <br /> _ ` <br /> '-Zc?---�--------���----------- � Permit No- -- �.��_�.J� <br /> (Complete in Triplicate) <br /> ----------------- ------------- --------- <br /> �- Date Issued '.__ <br /> --------!tie----- --- This Permit Expires 1 Year From Date Issued <br /> i trict�for permit to construct and install the work herein <br /> Application is hereby made to the San Joaquin Local Health D s p <br /> described.•This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> ] / / �'-- ---------------CENSUS TRACT �Jb <br /> JOB ADDRESS/LOCATION --------------+r!' ----�J--a�� fJ -- <br /> Owner's Name r-- ------Phone ----------------- <br /> v£ Cit /_ `_ %--------------------------------------- <br /> Address ----- ---- ----�---- ----__ tL'�i Y t <br /> Contractor s1Name r�i�"w--- -------------------------- ----I License #�--��.-- phone' --- - <br /> Installation wilkserve: Residence [Wpartment House❑ Commercial ❑Trailer Court ❑ i <br /> 1 <br /> •,.-„,��, _Motel ❑ Others-- r--- -- —>...---------- <br /> umber <br /> ----- ._ <br /> Number of living units:_-/__.Number of bedrooms _- `__Ga gage Grinder __ Lot Size--�--k--��----------- <br /> Water Supply: Pu.bIic System andd�name�_L.� r--_�G, ' --- -- - �- �SanL,9_o�arrx4”- <br /> '----------------•---------Private ❑ <br /> J - <br /> Character of soil to,11 a depth of 3 feet: "Sand'❑ Silt❑ } Clay ❑ Peat❑ 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 /> of <br /> PACKAGE TREATMENT [ ] SEPTIC TANK'[f] Size----------------------------------- --------- Liquid Depth ------------------------- <br /> Capacity - ------------------ Type ---------------- --- Material------------ --------- No:' Compartments I <br /> Distance to nearest: Well -----------------}------------.-----Foundation ----: _-_--- Prop. Line <br /> LEACHING LINT: [ ] No. of Lines ___________ ____________ Length of each line----------------- <br /> - Total Length <br /> -�- --__I----- <br /> 'D' Box ----------- Type Filter Material _�_______________-Depth Filter Material ----- _____________-___ ---------------- <br /> ---------------- <br /> Distance to nearest!Well --------------------=--- Foundation ----_------------------- Property Line ------------------------ <br /> ! a <br /> SEEPAGE PIT [ ] Depth ----_.___f_--______JDiameter -----------_ __._ Number ____-.----_-._______-__ Rock Filled Yes ❑ No i❑ <br /> t` Water Table•Depth ----------Rock Size --------------------- --------- I <br /> 47 <br /> {s �� Distance to nearest: Well ____._Foundation __+ Prop. Line ________________ <br /> REPAIRIADDITION(Prev. Sanitation Permit,# _-_-- --,! ---------------------------- Date ___:______-.____ __________-----1 <br /> t s - t <br /> Septic Tank (Specify Requirements) ------------------ ------------ ' ` --------------------- <br /> Disposal Field (Specify Requirements) ^---------- -- _.@` "•" ` �: d <br /> `- ----------------- <br /> -- <br /> -- —------------------------------ <br /> ---- ---------------------------- ---------------------------------- ---- [f <br /> A <br /> (Draw existing and required <br /> addition on-reverse side),! <br /> I hereby certify that l have prepared this application and.that,the workfwill be done in accordance with San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Heid1h District.'Home owner or se11 licen- <br /> 5 <br /> d agents signature certifies the following: ) J <br /> r"1<�ertify that in the performance of the work'lfor which this permit is issued, I shall not employ any plerson in such manner <br /> as to become subject to Workman's Compen 'tion laws of California."f 1 I <br /> Viigned ------ I Own er1 !' <br /> BY ---------------------------- -- - ---- -- --- - ------------------------ Title <br /> 1/\ (If of an owner) <br /> F ARTMENT USE ONLY <br /> YAPPLICATION ACCEPTED BY _.._ . - -------------•---- ------ ------------------------- DATE j --------- <br /> BUILDING PERMIT ISSUED ---- ! DATE r --------- ------------------------ <br /> / DDITIONAL COMMENTS ---- - - - --------------- ------- ----------------------------------------- ---------------------------- --------------=--------------------------- <br /> 1 4 I ----------- <br /> --- ----------------------------------------------------- - <br /> --------- f----------------------------------------------------------------------------------- <br /> i --------- --------------- ------------- ----------- <br /> - - <br /> --------- ------------------------- ------- ------------------------------------------ <br /> ------------------- <br /> Date <br /> Final Inspection by: ------ - '"J--V------------------------- —/ G <br /> r /SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> v <br /> E. H. 9 1-'6$ Rev. 5M <br />