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k <br /> FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT / <br /> Permit No. -- (.----------- <br /> ----------------------------------------------- ---------- (Complete in Triplicate) / <br /> ----------I---------------------------------------------- Date Issued <br /> This Permit Expires 1 Year From Date Issued <br /> Application is hereby made tot San Joaquin Loco ealth District for a permit to construct and install the work herein <br /> described. Th' a lica i n de in compli nice <br /> it Counntty. Ordinance No. 549 and existing Rules and Regulations: <br /> } ^w <br /> /s <br /> � ��- _C�rrriCENSUS TRACT -- ------------------------- <br /> is <br /> JOB ADDRESS/LOCA N .10-�---- �c�----I�---L-�r�--- --- ----- <br /> Owner's Name ------ ----------- '----------- ----------••- <br /> ---------------------- --------------- <br /> ---------------Phone ----------------------------- <br /> •kms. �------- urs <br /> Address _ - ----------------------------------------------•.. City ---�------------------------------------------------------------ <br /> Contractor's Name -------- ------------� lalt✓---------------------- <br /> License #a _----- Phone --------------------------• -- <br /> Installation will serve: Residence []Apartment House❑ Commercial [-]Trailer Court ;❑ l <br /> Motel ❑Other ----------------------------------------•--- <br /> Number of living units:_._ ----- Number of bedrooms ---- ----Garbage Grinder "`__-- Lot Size -------- <br /> Water Supply: Public System and name ----------- - AU �---- -----------------Private <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loom -❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe 2,'Fill Material ------------ If yes,type --------- ------------------ <br /> (Pl'ot 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 /> PACKAGE TREATMENT [ SEPTIC TANK'[ ] Si`e---V_x-�- -- ----------------------- Liquid Depth ---�-17--•-------------- <br /> Capacity _'X014'-_------ Type -- 5------- Material---GV'±��'-_---- No. Compartments ----�---_------ J <br /> Distance to nearest: Well ____----- _------------------Foundation ----w------------- Prop. Line_IA-',---------------� <br /> LEACHING LINE [ ] No. of Lines ------3--------------- Length of each line........ ------ ------ Total Length ,-' 7��--------- � <br /> 'D' Box _�e_>---- Type Filter Material -_ ------Depth Filter Material 12 -.b <br /> Distance to nearest: Well -----------_-- -----_ Foundation ---tP_--------------- Property Line --- ----.--------•- O <br /> E SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No ❑ <br /> ty <br /> Water Table Depth ----------------------- ----------------------- <br /> _Rock Size ------------------------ <br /> - <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 /> --------------------------------------------------------------- <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 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 su ject to W rkman's ompensation laws of California." <br /> Signed -------- -- Owner <br /> - ----------- Title -- ------ -------------- -- ----------------------------------------- <br /> - - -------------------------------------- <br /> (If other than owner) <br /> FOR DEPARTME US LY <br /> APPLICATION ACCEPTED BY ------------------------ = . DATES�/ <br /> ---------------- ------- <br /> PPLI <br /> BUILDING PERMIT ISSUED ------------------------------------------ - ------------- --------- ----- --- -------------.-DATE _. <br /> -- ------------------ -------- - <br /> ADDITIONAL COMMENTS ------------------------------------------ ------------- ' <br /> i --------- --------------------------------------------------------I------------------- <br /> ----------------------------------------------------------------------------------------------------------------------------------- ---------- <br /> ----------------- <br /> --------------------------------------------------------------------------------------------------------------=------------- <br /> Final Inspection b ----- Date ---- ------ ------------ <br /> SAN JOAQUIN LOCAL HEALTH TRICT <br /> C� <br /> c u a 1-'AA Rav 5M r <br />