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FOR OFFICE USE: a <br /> APPLICATION FOR SANITATION PERMIT <br /> 1 .�� <br /> ......I——......... Permit No. ._. 72'. ............. <br /> (Complete in Triplicate) <br /> This Permit Expires 1 Year From Date Issued Date Issued .2- ....... 3 <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 /> JOB ADDRESS/LOCATION .: .�? �- Z'X. ......... ........CENSUS TRACT .......................... <br /> Owner's Name ._._.7:.... .�.:r.l. !!-.''J................ '._.. Phone .......:.............. <br /> ledAddress ._... �?- •, ^..-...._. .: <br /> ...----....� ..k:a--- 4­7........ ---------------------•---------.License # .•- ---------•--.............................................. <br /> ....'fix:. Cit <br /> Contractor's Name ....C. r 3 . Phone .......................:...... <br /> Installation will serve: Residence [Apartment House❑ Commercial []Trailer Court <br /> Motel ❑Other ........................:................ <br /> ... <br /> Number of living units:...... Number of bedrooms .....Garbage Grinder ............ Lot Size .... ------__-.__... <br /> Water Supply: Public System and name --- -------------------------------------------------------------------------------------------- ---­---------- <br /> Character of soil to a depth of 3 feet: Sand❑ .Silt❑ Clay ❑ Peat-❑ -- .Sandy Loam fff`� Clay Loam ❑ <br /> Hardpan ❑ Adobe.l] 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.) Q <br /> NEW INSTALLATION: (No septic tank or seepage pWpermitted If public sewer is available within 200 feet,[ <br /> PACKAGE TREATMENT [ ] SEPTIC TANK-1 ] Size....................................::<:...._..._ Liquid Depth .................... <br />� ..Capacity .._.....---•-------- Type -------------------- Material------...------- ----- No. Compartments .:.................. <br /> Distance to nearest: Well .........................:..........Foundation ....................... Prop. Line .................. <br /> i <br /> LEACHING LINT: [ l No, of Lines -._____________________ Length- of each line------------------__-.-----_ Total Length ............................ <br /> 'D' Box ..........:. Type Filter Material ....................Depth Filter Material -----------•--•----------- <br /> --------.___--._.. <br /> Distance to nearest: Well ........................ Foundation Property Line ._.__................... <br /> SEEPAGE PIT [ ) Depth .................... Diameter ----::.......... Number ............................ Rock Filled Yes ❑ No ❑ <br /> Water Table Depth ...........Rock Size <br /> Distance to nearest: Well .........:...............................Foundation .. Prop. Line <br /> REPAIR/ADDITION(Prev. Sanitation Permit#' ................. ........................... Date ---------_______•--------------_--) <br /> Septic Tank (Specify Requirements) <br /> Disposal Field (Specify Requirements) ..- ................ ............. <br /> ................................•------•---........... . ..---------••------•------------•---------....------...---._......._......._.._.................. ....................I........................ . <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 licew <br /> sed agents signature certifies the following: <br />` "I certify that in the performance of the work for which this permit is issued, 1 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 /> BY ....................................... Ila, - . ...... .Title ..��._.._......... ..._..........._..._..-•---••.._. <br /> (If other thannowner) ` <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY <br /> DATE ..... _ ._ l ........... <br /> BUILDINGPERMIT ISSUED -----------------------------------------..--.............................. ------- ---•...................DATE .......... ....................... <br /> ADDITIONALCOMMENTS ..................................................-............................................................................................................ <br /> .._..---•--••..............................•...._....-•-•- . ............ <br /> ............. <br /> . .. .. ........ <br /> FinalInspection by- -----------------•------_•.:.. .. -.......-----••-•---...---....------•......• •-- ........-. Date . ! ..... _. <br /> SAN JOAQUIN LOCAL' HEALTH DISTRICT <br /> c Li 13 24 , e__- t.. 7 17-) 't M <br />