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FOR OFFICE USE: - <br /> APPLICATION FOR SANITATION PERMIT <br /> -- --------- <br /> Permit No. ...:..._... <br /> # orn.viete in Triplicate) 7� <br /> ............. This hermit Expires I Year From Date Issued Date Issued <br /> Application is hereby made to the San Joaquin focal 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 <br /> �➢"-.......LQc '. . --.....CENSUS TRACT <br /> Owner's Name ...... <br /> ------ .� .............. <br /> ---•.........................................Phone <br /> Address Cf.��x.�. <br /> F............................. city - <br /> r <br /> Contractor's Name <br /> ..__...---- '&1-'1-�e---••.............. -------- ........License # ...._............. ...... Phone ................... s <br /> Installofion will serve: Residence partment Houseo Commercial oTraller Court 13 <br /> Motel 0 Other <br /> Number of living units:-:� "" Number of bedrooms U-- Garbage}Grinder ..--•-...... Lot Size <br /> Water Supply: Public System and name ' <br /> ....................................•- ..Private <br /> Character of soil to a depth of 3 feet: Sand 0 Silt 0 Clay 0 Peat❑ Sandy Loam lar", Clay Loam <br /> f Hardpan ❑ Adobe 0 Fill Material .... If yes,type ... <br /> ( F I <br /> (Plot plan, showing size of lot, :Iocationzof system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: <br /> (No septic tank atI i1 <br /> .seepage pit permitted if public sewer is available within 200 feet,) F 3 <br /> PACKAGE TREATMENT [ ] SEPTIC TANK. <br /> [ ) Size------------------------- . Liquid Depth .......... '---- <br /> Capacity ----------- <br /> TYPe Material---------------------- No. Compartments <br /> Distance to nearest. Well <br /> .___.-Foundation __ <br /> •-------.... .._ Prop. Line '... 1i <br /> LEACHING LINE [ ] -No. of Lines ................. <br /> ------:-Length of each line.................... -- Total Length <br /> D' Box-.-. .....-- <br /> Type Filter.Material ___Depth Filter. Materia! <br /> Distance to.nearest: Well .................... Foundation .... Property Line <br /> SEEPAGE PIT Dep,thDiameter Number ............................ Rock Filled Yes (] No ❑ <br /> Water Table Depth <br /> ...-Rock Size <br /> Distance to nearest: Well ......... Foundation <br /> .................... Prop. Line { i <br /> REPAIR/ADDITION(Prev. Sanitation.Permit ............. . Date <br /> Septic Tank (Specify Requirements) 47 <br /> Disposal Field (Specify R quirements) .-�L:Y.?_/ -4:2' <br /> , , l <br /> - � <br /> _.. ---------------•-••----......................................... ........... ................ --... ..... .� <br /> •-- ---- <br /> ....................................................._ <br /> = --(Drow-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 Been- <br /> sed agents signature certifies the following: <br /> "I certify that in the performance of the work for which chis permit is issued I shall not employ an <br /> p p y y person In such manner <br /> as to becam sub ct to ork an's Compensation laws of California." <br /> Signed . -- <br /> -- -- <br /> Owner <br /> By ...._..." - ---•• Title <br /> - ---------- •- --------------- <br /> (I <br /> —(If-other-than owner)—. ....... <br /> r R DEPARTMENT USE ONLY s <br /> APPLICATION ACCEPTED BY .­ <br /> DATE......���" .. d7.............. <br /> BUILDING PERMIT ISSUED ------------------- ---------- -- -.....----•-- -------•---- --_._._.:......----------,.... <br /> -------- ----------------". DATE <br /> ADDITIONAL COMMENTS ..._.... ......................... <br /> __... ............................................................... <br /> --•--•----.... . . . <br /> ...................................:.....................I.......... <br /> Final Inspection by: la.--- <br /> -•..........................r.........---.....------- . ------•..............Date . fr .7......_. .............. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT } <br /> t� 13 2 4 <br />