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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br />................................................I........ Permit No. ... .. <br /> {Complete In Triplicate) <br />--. <br /> .................................................. A. <br /> ..... This Permit Expires 1 Year From Date Issued <br /> Data 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/,ccompliance wi ounty Ordinance No. 549 and existing Rules and Regulations= <br /> 7 1"JOB ADDRESS/L tN .......-..-- .. ......... ........... ...�:�..�,..��,C':�/.................................-CENSUS TRACT .......................... <br /> T <br /> Owner's Name •............................... .............. - Phone ......- ...... <br /> address . -p7a -.....Q✓ - ----- -•..........City . ...... ... .. <br /> ... .... ..... ..... / <br /> Contractor's Name ------ --... :.°:.!....-- ----.... <br /> -- ..........................................License 1P ... Phone f7/�� ° /5..... <br /> installation will serve= Residence 01(partment House[} Commercial.❑TraHar[curt ❑ l <br /> Motel ❑Other ' - ` <br /> Garbage Grinder Lot Size <br /> Number of livingunita•_.._,� Number of bedrooms g ��a�`•�9/ <br /> Water Supply: Public System and name .--•-•---••----•.....................-•----------............._.....-•----..................................Private <br /> Character of soil to a depth of 3 feet: Sand❑ Slit❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loom ❑ <br /> Hardpan ❑ Adobe ( Fill Material ............If yes,type............... ............ <br /> 4PIot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed an reverse sldej;Z._ <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted If rublic sewer is available within 200 feet,) f <br /> PACKAGE TREATMENT [ ] SEPTIC TANK{�,}� SIz .7..�4? i?.'1� .................... Liquid Depth ....7/............... <br /> Capacity -D •----- TypeV P..e. . ..._. Material....... No.If Compartments .... �....... <br /> /aa -_ w..� . - <br /> . Prop. <br /> Lute:. .. ?.......... <br /> Distance 'to•naareat: Well- ....................................Foundati n�.x�........._.. <br /> p <br /> _EACHING LINE [ No. of Linos ---�.............. Length of each i1ne..� D.-g. �..` Total Lengttth .47.4••...... <br /> 'D' Box -.../..... Type Filter Material 454 i4c-4.)...Depth Filter Material .../S/...................... ..... <br /> Distance to nearest= Well .../kA-, � Foundation ...V+lP. ......•.. Property Line c. ..`......... <br /> SEEPAGE PIT le Depth .p;?.S.......... Diameter .'32....... Number .......a........ 4.... 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 /> SepticTank ISpecify 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 Ilcew <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 /> s to be Islect t rkm n's Compensation laws of California." <br /> � <br /> ogneu' ~.... ..................................... ............. ..._.. Owner <br /> - rifle .- .....-. ........................................... .... <br /> SII other than owner) / <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ......... . .................................I................... DATE -.....,.9.�.3. ...7:(�.....: <br /> BUILDING PERMIT ISSUED -.DATE> <br /> .ADDITIONAL COMMENTS ...... .. . . ............................................... <br /> - ----.-_.................................................................................................... ........................... ....................... <br /> ................... - _' ..-.....-•--•---------- .--... .,.--_........--.......... ..... .....--......-.... ....................................... <br /> Dat --. . .. .7 <br /> ............................... e <br /> Final Inspection by: -...----.------- .-. .. .-•- •--•----- ----------------------------.----•• ���� <br /> M 13 2!t 1-69 Rov. 53�I SAN JOAQUIN LOCAL HEALTH DISTRICT 8/74 3M <br />