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y,FS 3"I'OR OFFICE USE: � \ <br /> APPLICATION FOR SANITATION PERMIT <br /> ------ <br /> (Complete in Tiiplicate) Permit No. <br /> i <br /> This Permit Expires 1 eYear From bate Issued Date Issued <br /> ----------- ---- <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 /> JOB,'ADDRESS/LOCATION d-- & <br /> ..... <br /> �y <br /> - <br /> CENSUS TRACT <br /> Owners Na ,gZ1X / ffL---- ;y Phone 3 <br /> Address �J_ X9' <br /> i <br /> .-eo�----------------------- ---------------_. City ......... <br /> Contractor's Name _ <br /> 11/� .--------i--License # 17Phone <br /> Installation will serve: Residence;gApartrrient House❑Commercial:❑Trailer Court i❑ <br /> Motel ❑Other -------------- ---------------------------- <br /> Number of living units:--_l----- Number of bedrooms __c�-----Garbage Grinder Ala_ Lot Size _A1 ------------------ <br /> Water <br /> -___________.Water Supply: Public System and name ----=----- ----------•---------------------------------------------------------------------------------------Private ❑ <br /> Character of soil to a depth of 3 feet. Sand ;Silt❑ + Clay ❑ Feat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ AdobeX 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 /> F , f /� or <br /> PACKAGE TREATMENT [;] SEPTIC TANK' Size-- a aCS -- --- ----- Liquid Depth -' __----_'_:-y__,___.- <br /> Capacity4l,9�_ - Type �7/_�� Materiae,0"ZV No. Compartments <br /> --------------- <br /> l - e <br /> Distance to' nearest: Well y_______________________Foundation - -------------- Prop. Line ---I--------------.__ <br /> LEACHING LINE pf No. of Lines ------1--------------- Length of each line------)0-d-_----------- Total Length __ - - ----_-____________ U <br /> 'D' Box)e-0.-... Type} Filter Material _/ G�C____Depth Filter Material --If---.______._``_________________•- <br /> Distance to nearest: Well -------------------______ Foundation ----------------- !Property Line -------------___________ <br /> SEEPAGE PIT Depth _4A,�7/.----- Diameter •3 ________ Number -- 1�. ��___ Rock Filled Yes. No 0i <br /> Water Table Depth -p----` --- <br /> ------------- <br /> ---��a--- -------- - - --------- - <br /> Distance to nearest: Well -------- -----------------------Foundation _10------------- Prop. Line — --- ------------ <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ---------------____._ I <br /> ----- Date --------------------- ------------ <br /> iSeptic Tank [Specify Requirements} ------- ------- -------------------------------------------------- -------- --•.-------------------------- <br /> Disposal Field (Specify Requirements) -----1------ ---------------------------------------------------------------------------------- '---------------------------------- <br /> -------- -------------------------------------- ---­------------------------------------------- ------------------------------------------------- ------ ! <br /> --------------------------------------------- -------------- ---------------------------------------------------------------------------------------------------------------------- <br /> (Draw existing and required addition on reverse,side) i - <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with Son 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 become subject to orkman's Compensation laws of California." <br /> l <br /> Signed ---------------------- -----#-- <br /> ------- -- ------------ ------------ ------------- Owner <br /> BY ------------------- '� Title ------------------ <br /> (If they an owner) <br /> FO A1tTMEN7 USE ONLY <br /> APPLICATION ACCEPTED BY ___ ___-_______- DATE ---.1'7=13____��yy <br /> BUILDINGPERMIT ISSUED ------ -__ _ ----------------------------------DATE -------------•----------------------- <br /> ADDIT�O'�L COM TS ---- - - ---- ---- --- --- . -------------------..---------------------------------------------------------------- -------------------- ------ <br /> ----� - --------- ------- -- T--- - ---------------------------------------------- - --------- ------------------=--- __::_ :__: _:_ --_= _:___--::_ <br /> --------------------------- -------------- ------ ------ ------------- <br /> -- - - - _ _ _ <br /> / h <br /> FinalInspection by.. --- '--- --- -- =-.- - - -- -------------------------------------------- --------------------------------Date ---�--`��-�T/......-------- <br /> 1. ,_., JOAQUIN LOCAL HEALTH-,.DISTRICT <br /> E. H. 9 1-'6$ Rev. 5M <br /> � S <br />