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f <br /> FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> � 3 <br /> -- ---------- ------------------------------------------ <br /> Permit No. ------------ - -- <br /> - - <br /> [Complete in Triplicate) <br /> = ' <br /> --------- -- ----- ---------------------------------- p - ,. <br /> _�- <br /> This Permit Expires 1 Year From Date Issued Date Issued <br /> Application is hereby made to'tlie San Joaquin Local Health,[)!strict for a permit to construct and install the work herein <br /> described. This application is made in compliance with County Ordinance No. -544 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION . ": -- - 7- ---- rt��S TRACT <br /> -- ------- ---- - - - - <br /> Owner's Name - = = -.Phone ----------------------I------------- <br /> Address ---- 1 '--- -----•--------. ------------------------------------ City c7h <br /> Contractor's Name _-_ _. -: / --- License ��,�- � Phonef <br /> f <br /> Installation will serve: Residence Apartment House�❑ Commercial []Trailer Court ;❑ <br /> Motel ❑Other -------------------------------------------- <br /> Number of living units:----/ ---- Number of bedrooms -_ -----Garbage Grinder/-W-— - Lot Size -- <br /> - --------------- <br /> Water Supply: Public System and name -------------------------- -----------------------------------------------------------Private , <br /> Character of soil to a depth of 3 feet: Sand'[:] Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loom .E] <br /> Hardpan ❑ Adobe Fill Material ------------ If yes, type ---------------------------- r <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic flank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ SEPTIC TANK'[ ] Size------------------------------------------------ Liquid Depth -------------------------- <br /> Ca acit Type Material---------------------- No. Compartments ------_-"--------_____ <br /> Distance to nearest: Well -------------------------------------Foundation ---------------------- Prop. Line -------------------- <br /> LEACHING LINE [ ] No. of Lines ------------------------ Length of each line---------------------.------ Total Length _-----_---.---.-----.-•__-. <br /> 'D' Box ------------ Type Filter Material --------------------Depth Filter Material -------------------------------------------- <br /> 1 - Foundation ------ Property Line ------------ ` <br /> Distance to nearest: Well �---------------•------- Li -----••"-"-- <br /> SEEPAGE PIT [ ] Depth ---- Diameter -----------------Number ---------"------------------ Rock Filled Yes ,El No 0 <br /> WaterTable Depth ------------------------------------------------Rock Size ---.-----_--------------------- <br /> ` Distance to nearest: Well -------------------"--- Foundation -------------------- Prop. Line -----_--------_.__-.. <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------- ----------------------------------- Date -_----"--------------------------) <br /> Septic Tank (Specify Requirements) ------------ --- -------- - <br /> " --"- ""-".- -- ""---."""---Y-- - <br /> y� <br /> Disposal Field (Specify Requirements) �- ------------- X-//Z,------- ¢ a -- ----------------------------- <br /> ----- .�-: ,/_!i Z6 �� W'eo ---------------------------------------------------------------------------------------------------------------------------------- <br /> Draw existing required addition <br /> ----------------------------- <br /> -------------------------------------- ----- <br /> -------------------- - <br /> ( g q dition 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 such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed -------------------4thowner) <br /> ---------- ------------- ---- ----------------------- Owner <br /> Title �t2t <br /> BY -------- ----------------- ---- r <br /> -- - ----------- <br /> [If otr) FOR DEPARTMENT USE ONLY <br /> APPLICATION ACC -- - - -------------------------------------------- DATE --------------- <br /> BUILDING PERMIT ---- ------------ -----DATE -------------------------------- ---------- <br /> - -------- - <br /> ADDITIONAL COMMENTS - - <br /> ---------- ------------------------------------------------------------------------------------------------------- <br /> ------------------------------------------------ ----------------------------------------------------------------------------------------------------------------------------------------------- <br /> ------------------------------- <br /> ----- _44\- <br /> Final Inspection by: " Date -------------------- -------- <br /> -------------------------------------------------------------------------------------------- -- -- <br /> - - - -- -------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> C yG <br /> F N 4 1.'AR Rev- 5M <br />