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FOR C►FFId 6iE: .., _.� <br /> I ApPLICATIC?; t SANITATION PEttM1 <br /> ......... ........ ..................:------------- Permit No./ <br /> {Complete in Triplicate} <br /> _�_,... <br /> This Permit Expires 1 Year From Date Issued Oate Issued ^f -- -- <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 complian with Co nt ry Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION ... <br /> ..L?... CENSUS TRACT <br /> Owner's Name It . •.. ................................................................................Phone ......... ,...................... <br /> Address . - ..... .. .... . . . — city ...................................,............ .... <br /> ---._.... - = . ...-----.License # ........................ Phone <br /> G.�.... `- . <br /> Contractor's Name ••r••••3`- .....�"C�'•- <br /> installation will serve: R side Z❑Apartment House❑ mmercia) ❑Trailer Court 0 <br /> Motel ❑Other ._ ----_----- ..:........ ................ <br /> Number of living units:.... Number of bedrooms _ .l. .....Gorbage Grinder ............ Lot Size ... ........... ' <br /> I Water Supply: Public System and name ...........:.. ...Prlvcte ❑ <br />' Character of soil to a depth of 3 feet:. Sand o Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam,q CU <br /> r <br /> Hardpan ❑ Adobe ❑ Fill Mpterlol ............ If yes,type ............... ............ <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.)calq <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT ) ] SEPTIC TANK I ] Size..... ,.- -- (-..�0......... Liquid Depth ..Z".,`................. <br /> d Capacity/__ D_-._ Type ........ Material. ------ No. Compartments ...11 ............ <br /> Distance to nearest.• Well .. ..Foundation a ... Prop. Line <br /> i LEACHING LINE [ ] No. of Lines ,..................... Length of each line.---- Total Length .-. <br /> 'D' Box .... Type Type Filter Material ....................Depth .Filter Material ........ .............................. <br /> Distance to nearest: Well ........................ Foundation ---....._.... .......... Property tine ........................ <br /> ' SEEPAGE PIT ( ] Depth 9L.Aff�IODiometer ................ Number ........I_..... ............. Rock Filled Yes V No i❑ <br /> Water Table Depth ----=-------------------------------- ----------hock Size .....----................... <br /> Distance to nearest: Well ...:....................................Foundation -------- ....... Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit+# ........ __.................•.._._.._. Date ................................ <br /> SepticTank (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 suclii manner <br /> as to become sub'ect to Workman's Compensation laws of California." <br /> Signed - - --------- -- -- ----- - ---- ----•-•-----------_----- ----- --------.- Owner <br /> i BY ----- ------ ---- -- --- ----- -- -- --� -------- - ---- -------- - ------- <br /> ...- <br /> r llf o er tha owner) <br /> FOR DEPARTMENT USE ONLY <br /> - <br /> .. yDATE .- �' <br /> APPLICATION ACCEPTED BY - ------------- --------------- ----- <br /> BUILDING.PERMW ISSUED ---- -------- ----- ----------------------------- - <br /> r <br /> ------ - -------- ----------------------DATE ......._....................... <br /> ._...-.. <br /> ADDITIONAL COMMENTS --------------------------------------- ------------------------------ ....---------•................................................................... <br /> ......_ <br /> ---------------- -----• - --------..__.....--••-- ------ ---------- ..-_--- ..._......-- .. <br /> ........... ---...__. <br /> final Inspection b <br /> .: Date ............. <br /> EH 13 24 1--68 0��SAN JOAQUiN LOCAPiHEALTH DISTRICT 6/7h 3M <br />