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['VK OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> IComplefe In Triplicate) Permit No. 7f 3... <br /> -----------------.•••.•-------- This Permit Expires 4 Year From Date Issued Date 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 ade in compliant with County.Qrdinanco No. 549 and existing Rules and Regulations: <br /> J013 ADDRESS/LOC 10 ........CENSUS TRACT <br /> Owner's Nam t ��......... <br /> o <br /> Address , -- ... `..... !- -d _...... .... <br /> Ph ne :. . <br /> .. ............. City _.. .. . ....... ..._. ... .......... <br /> Contractor's Nome ............................ License 91t <br /> ......•---............---.........--- ... Phone <br /> Installation will serve: Residence Q Apartment House f] Commercial ❑Traller Court 0 <br /> Motel ❑Other....--••---- <br /> Number of living units:...__- Number of bedrooms _.Garbage Grinder Lot Size <br /> Water Supply: Public System and name .............• .............Private ❑ <br /> Character of soil to a depth of 3 feet: Sand 0 Silt❑ Clay ❑ Peat Sandy Loclm Clay Loam ❑ <br /> Har an Adobe ❑ Fill Material .... .... If yes,type............... ............ <br /> (Plot plan, showing ssiiz'ra�ot, location of. stem in relation to wells, buildings, etc./Must be placed on reverse side.) <br /> NEW INSTALLATi Ir`i (No septic tank or seep ge pit permitt ublic sewer is available within 200 feet,) <br /> PACKAGE TREA MENT € ] S PTIC TANK f SizeLiquid Depth <br /> ...................... .. �...., ....... <br /> .......................... <br /> opac ry - .... Type •...... " Material... ....... .. .�` No. Compartments ...... <br /> Distance t crest: Well ---- - d.......................Foundation .............. Prop. Line <br /> ---.. ............ <br /> -- <br /> LEACHING €I E ) ] L' es --- ---- - - ----- -- Len th of ea line. _10_411F-17. Total Length .a .:® <br /> 'D' Box .. ........ TYp ilte er! I . <br /> I <br /> pth Iter Material ......................I..................... <br /> Distance to nearest: Well . _ and on ... ----I.............. Property Line ........... <br /> .........."" <br /> SEEPAGE PIT O Depth .............. ..... Diameter ................. umber ............1.............. Rock Filled Yes (3 No 0 <br /> ater Table Depth ..................................... .....Rock�Sizel... ............................ <br /> Dist a to nearest: Well ................................. . o ndatl'lo .................... Prop. Line .................. <br /> REPAIR/ADDITION{Prey. Sanitatio ermit# ---•---------------------------------------- D to .. ..............................) <br /> Septic Tank (Specify Requirements) -----_-•-- ---------------•------------------ <br /> Disposal <br /> --.._.--- ----Disposal Field (Specify Requirements) ------------------- ------ .. <br /> - ------------------------------ <br /> ,............ <br /> I................. <br /> . <br /> ----------- ------------------------••----------------•-----•-•. -----------------------------------------­......................-............... ... <br /> -------­---------------I------------------ ------------------------------------I--------------1-1---- -------------- ......... .............­................................. <br /> (Draw <br /> ------ ----- <br /> (Draw existing and required a dltion on reverse side) <br /> I hereby certify that 1 have prepared this application and that�the work will be done in ccordance with San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations a the San Joaquin Local Health.01strict. Nome owner or licen. <br /> sed agents signature certifies the following: <br /> "I certify that In the performance of the work for which thi permit Is issued, 1 shall not employ an arson In such manner <br /> as to become s bl t to Workman' o nsatian laws California." <br /> r � <br /> Signed __.. .. -••------ <br /> ........ ------ ...... Owner 4 <br /> By __---------- -.-------------- •---------------- ---------•- -------. Title ---------- <br /> (If other than owner) <br /> DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ...... - �' ' <br /> ------- •------•----........ --------- --- <br /> DATE <br /> BUILDING PERMIT ISSUED -, ---------- --- _._....DATE .................................... <br /> ADDITIONAL COMMENTS ------_•-----------------• .- <br /> Fi--------------I--- -------------.-•-------------.._...-_-----...--------------................. --------------••-•-- ------.._.-..--._.----- ----- ............---..................................... <br /> nal Inspection by- ----------------- ._...----------Date ......--....---- ...... <br /> EH 13 2a 1-613 �v. � - - .................... <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT 8/711 3M <br />