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�- FOR OFFICE USE:3 0 APPLICATION FOR SANITATION PERMIT 7rel d <br /> ? ........................:. ... Permit No. � <br /> iComplete in Triplicate).. <br /> ........................................ - _ Date issued <br /> ..:......................................W............... this permitExplres t Year From but*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 w' unty Ordinance NO' 549 and existing Rules and Regulations <br /> JOB ADDRESSAOCATION def. <br /> ...........CENSUS TRACT :.. <br /> Owner's Name .:. _. .......... Phone <br /> Address .... . .r ..,City ...........................`..y .......... <br /> Contractor's Name ... ...,.:..........License 1.,j� <br /> Installation will serve: Resldeme Q Apartment Housefl Commercial QTra#ler Court � <br /> Motel Q Other....-- .............. .........:..:..:.. t, = <br /> Number of living einitst............. Number of bedrooms ..- ,....Garbage Grinder Lot Size <br /> Water Supply: Public System and name ......... ........................................._.. .............................,................Private Q <br /> Character of sail to a depth of 3 feet: Sand Q Silt Q Clay p Peat Q Sandy Loam (3 Clay loam - <br /> Hardpan[� Adobe� Fill A46terial ............If yws, <br /> h► . <br /> { <br /> {plat plan, showing size of 'lot., location of system in relation to wells, buildings, etc must be placed on revere sl OV\ <br /> l NEIN INSTA"VON& (No septic tank or seepage ,pit permitted if public sewer is available within 204 feet,} <br /> E PACKAGE TREATMENT SEPTIC TAMC I ] J� v . Size..... . Llquid Depth ....... <br /> Capacity 1z ? Type s i. 42iA-Y No. Compartments ......Z... .. <br /> Distance.to nearest: Well .. . undation .!.. Prop. Line . .. <br /> ... Le th of oath Itne..:. . • .-- Total Length .. ... . <br /> i LEACHING LINE ` ] No. of Lines .... . ..... rt8 1 f <br /> •p' Sox . . :._... Type Filter Material .... .Depth �Fllter Matcrtal .... 6 . . ........ ...... <br /> Distance to near t; WeV Foundation _.................. ..--- Property rty Line ....................... <br /> • <br /> SEEPAGE PIT [ ! Depth ...../- ..... Rack Filled Yes (R No 0 <br /> am ....---•__-• Number ... ._ .._....... <br /> Water able Depth ' .. .. ....``..""�� . ......Rock size ..... <br /> , <br /> Distartce to nearest: Well ..� e411&...1d n.: ..Foundation ................. Prop. Line ...................... <br /> R PAIR/ADDITION(Prey. Sanitation Permit dt :. . ........ ........:........ Date ............................... <br /> } Septic Tank (Specify Requirements) ........................................................................................................................_..-................. <br /> _ <br /> ,Disposal Field (Specify Re uirernents} •--..•............................................---•-._....---........... ............................................. <br /> P.......... ..................................... ...........------...........-- ---:...........................I........................... <br /> + � - accordance with San ••-. ' <br /> _ --•---.- .... Y <br /> w._.. ........ <br /> (Draw existing and required addition on.reverse side) <br /> I hereby. certify that I have prepared this application and that the work milli be done in acco J" IR <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health:District. Home owner or liars• <br /> sed agents signature certifies the following: <br /> r "I certify that in the performance of the work for"which this permit Is issued, I shall not entpioY anY Person I" such inasttur; <br /> i <br /> as to become b t orkman' mpensatiY-6 <br /> California:' <br /> OwnerSigned ..... . .. ... ...... .. .. ...�- --•�-�--��� --------. .._............................. ...__.._....----....- ---•- <br /> itie . - .............•----.._........._.._..._......_.. <br /> (if other than owner) ' <br /> FQR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY .... .. . ......:..... ............................................. DATE ....... <br /> IBUILDING PERMIT ISSUED.---... ...................... ......................................................................DATE ............................................. <br /> ADDITIONALCOMME.NTS _.............•• ............................. - ..............................................--........ <br /> ..............................•-- ---...-•---•---------------. --•-•--•--- ..................................................._...................................... <br /> _..._...... t--- �_....... ........................................:..............-----_-..._..-- ---- .. <br /> Final Inspection by: -�' .... ...Date . �� ... <br /> f� <br /> EH 13 24 1-68 Rev. 51 SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7� 3M <br />