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a <br /> FOR OFFICE USE: <br /> 11 APPLICATION FOR SANITATION PERMIT <br /> 1I <br /> (Complete in Triplicate) Permit No: <br /> ______I1____ � <br /> This Permit Expires 1 Year From Date Issued Date lssued `` r: - <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. 0 L� �1---- ----------------------CENSUS TRACT --_____--_-_-____________ <br /> Owner's Name ------- ------f�^ -- ---- -- --------------------------------------------- - ------Phone <br /> Address ---------- -- +r ► Y <br /> -- -- -------- --------------- - ---------• Cit - - --- ----------------------------------------------- <br /> Contractor's Name -- -- - ------------- ----------License --------- Phone ------------------------------ ' <br /> Installation will serve: I Residence Apartment House❑ Commercial:❑Trailer Court ] <br /> I _;Z_ k. <br /> Mote[..❑,Other_------ ------------------------'-------- <br /> ` ,_ r. <br /> Number of living units:_---I'!- - li <br /> --- � �— �O t Size --- =V--x-1 L�----------------- <br /> -Numbe <br /> - 1 <br /> Water Supply: Public System and name r�of�bedrooms----- <br /> -------------------------------- <br /> --_--- G�rba e-Grinder• t Private ❑ <br /> Character of soil to a depth'of'3,feet:_,_,San_d;❑ - Silf[] 0a;" Pe' ,❑ Sandy Loam ❑ Gay Loom.E] <br /> it Hardpan ❑ Adobe V Fill Materia al �.-:_�If yes, type ____________________________ <br /> (Plot plan, showing size of lot, location of system in relation to wells aildings, etc, must be placed on reverse side.) <br /> INSTALLATION:NEW i' septic tank or seepage pipublic t permitted if sewer is a4lable within 200 feet,) U� <br /> PACKAGETR TREATMENT NT { ]' SEPTIC TANK. ]i Size-- ----- __________ Liquid Depth -------------------------- <br /> Capacity <br /> ---_--__-______Capacity ------ .. YPe -------------- Material-- <br /> ------ - ------- No. Compartments <br /> T <br /> Distance�e to nearest: Well ------------------------------------� Foundation ------:--------------- Prop, Line ---------------------- <br /> LEACHING LINE [ ] No. of Lines ---_ - Length,ofreach fine- __________ _______ Total Length ---------------------------- <br /> 'f I <br /> Filter Material _______-__ <br /> Box -__.-__-.- Type' ________Depth Filter Material - <br /> DDistance to nearest: Well ------------------------ Foundation J--__I-.-_-_---_-______ Property Line ------------------------ <br /> ' <br /> SEEPAGE PIT [ ] Depth ______.._.______-__ biameter ===:_ _____ Number.--_I--___v_.-_-_I.--______ Rock Filled Yes ❑ No i❑ <br /> Water Table Depth ------------J--------I-- ....... ---Rock Size-------------------------------- <br /> Distance to nearest: <br /> .y <br /> Well _______________t-------1_______._ ...Foundation 1---_---.___________ )P <br /> rop. Line --_.-____.___--___--__ <br /> REPAIR/ADDITION{Prev. Sanitation �t # •------ --------------- ---------- Date ---_-------------------erm ------____- <br /> Septic <br /> Tank (Specify Requirements) ---- ____________________ ",. y __ <br /> Disposal Fie d (Speafy Requirements)..,.. -- <br /> i r 'w.1 -------------- <br /> t , <br /> -------------s---------------- <br /> 1. <br /> ---------------- ---------------- <br /> i (Draw existing and required addition on reverse side) <br /> 1 hereby certify that I havle prepared this application and that fthe work will be done in accordance with San Joaquin <br /> County Ordinances, State Laws, and Rules a d Regulation of the San Joaquin Local Health District. Home owner or liven- <br /> sed agents signature certifies the following: r <br /> "I certify that in the performance of the work.for which this per it is issued, I shall not employ any person in such manner <br /> as to become subject to Workmt on's-Compensation-laws.of tCalifornia." <br /> Signed ------------------------------- --------- --- ------ Owner <br /> B �' � � � - � <br /> w — Y: Rit G� .*------- ---- <br /> ----------------- ---- <br /> (If other n1owner) <br /> i, FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED 13Y b ---- - DATE ---� �' -------------------- <br /> BUILDING PERMIT ISSUEDiE- ----------------- ------ ----- <br /> - ------ -- ---------------------------------------.._DATE - ----------- <br /> ADDITIONAL COMMENTS 1I_________________________________ <br /> ------------- <br /> ------------------------------------------- L---------------- ----------------------------------------------------------- <br /> --------------------------------------------p-------- �^ <br /> -----I-Y12D <br /> - - <br /> - -- -- -- - ------- -------- --- ------------ -- <br /> Final Inspection by: ate ` <br /> ---------------- - - ------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'6B Rev. 5M <br />