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FOR OFFICE USE: <br /> rti 3� APPLICATION FOR SANITATION PERMIT <br />,.....................1111-.................l. ...... <br /> (Complete in Triplicate) <br /> Permit No. 1111...-1111.. <br /> ............................... ......•---- <br /> T. <br /> .- This Permit Expires y Year from Date Issued Date Issued ..G.�,........, <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 Count Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADQRE55/LOCATI .......... ....f ...... ...................................CENSUS TRACT ......... <br /> Owner's Name ... L�.........._X_'X. .�. <br /> a. <br /> --Phone ............... <br /> Address ... •" ... --..-1111.- ....fi...-1111 City �,................ ... <br /> F � <br /> Contractor's Name -,_ ---_-_-- _ �.�, .. Y _.�+-c.e,.t License # iC'. ' 1.��.. Phone <br /> Installation will serve: Residence Apartment House❑ Commercial ❑Trailer Court 0 <br /> Motel E]Other ----•------- .............-1111.............. <br /> Number of living units:-..:- - Number of bear oms -_►2.....Garbage Grinde 'Lot Size <br /> Water Supply: Public System and name .---.-.. -.. �,1 ----••---__--...--•---------------111 ..............Private <br /> ❑ <br /> � ��1 ..... <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peut❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe Fill Material ............ 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.] <br /> NEW INSTALLATION: {No septic tank or seepage pit permitted if public sewer is available within 200 feet,} <br /> 4 �� r! <br /> Fi PACKAGE TREATMENT [ a SEPTIC TANK� ],�`i�' ��............................................. Liquid Depth <br /> .............................-----_-•--111:1.--.........._S <br /> Capacity ----------- -•-- Type ... Materia(.................1111. Na. Compartments ...:............ <br /> Distance to ewell .............. ..•__-_-____•-_-_-_Foundation .......................,Prop. Line ......................t_ <br /> j <br /> + ��drre .. <br /> o ....--....--- Tota( Length -••.........................mnLEACHING LINE s _-- Length of each line............ <br /> I <br /> 'D' Box ------------ Type Filter Material .Depth Filter Material <br /> •--- -1111----•--...---- ...........1 .............................. <br /> Distance to nearest: Well ,-_-1------------------- Foundation ......................... Property Line ................ f <br /> SEEPAGE PIT Depth Diameter IV-"... Number .....-c-2................ Rock Filled YesV No <br /> Water Table De` th_...... .. ` _. --- ..-.... ...r .. <br /> Rock Size <br /> P �-•---•--- ---- ----------------11.11... <br /> Distance to nearest: Well .. . .........Foundation ........... Prop. Line ............. 3 <br /> REPAIR/ADDITION(Prev. Sanitation Permit 4 -•.:------------.--------..............: Date ___............................... <br /> J <br />► Septic Tank (Specify Requirements} ................... .. .... ....................................... ........w. -1 .}1111-...- <br /> Disposal ield {Specify Requirements) r.... .......,7 _111._.1_ .............. <br /> �„_----- <br /> �. ..-... ----._ .....................••----....-- <br /> ....-..-- -- <br /> tR 1111..�.-.. -- _ <br /> .- .-.. -al� ►�-.. -1 .----._- :� ......................... ....._.___.-__...-----.-._..-.............................. <br /> IQraw axis ' g and requ' ed 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, Horne 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---------- ---. ......x.......................... <br /> 1s1...11,... 1.111--.. Owner <br /> � . eTitle <br /> ........................ <br /> BY ------ - - <br /> I Ilf other than owner} <br /> APPLICATION FOR DEPARTMENT USE ONLY <br /> ACCEPTED 8Y 1111. 1111. ,... ,..1.1.. DATE _1111 " _.0`- 1111... <br /> BUILDING PERMIT ISSUED .............................. ...... ..... ....... ........DATE ................I.................... <br /> .. <br /> ADDITIONAL COMMENTS :............ .....•------------------•------•----........:•...........................................:......................................... <br /> ........... <br /> .................... ...... •-- ......_. ._....--- .Date .. :.�.f .._- <br /> ...:--.... . <br /> ........... <br /> . . -- - <br /> -- _:. . 1111_ .-.. <br /> I Final Inspection by: __... :... .. ,/ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT y� <br /> E. H.13 24 1-'68 Rev. 5M - -- 7172 3 M <br />