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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PlERM17 <br /> .......... --------- ...... <br /> ....... <br /> lComplete In Triplicate) V Permit No <br /> .............................................. <br /> ....... .......................... .................. This Permit Expires I Year From Date Issued Date <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 /> Z� <br /> JOB ..........z;i1io./ow...CENSUS TRACT AA..... ....... <br /> Owner's Name ----en.................... ................. ..............Phone .... ............ ................... <br /> Address City ...... <br /> Contractor's Name ---if .......... ............ ..................License # a451-41?*... Phonel�tl'R...... <br /> Installation will serve, Residence 0 Apartment House C) Commercial OTroller Court 0 <br /> Motel []Other............................ ................ <br /> Number of living units._ Number of bedroom ...'..Garbage Grinder ............ Lot Size <br /> Water Supply: Public System and name ..............................:.._•----------•-•-...•------_.._-.........-r <br /> ...Private <br /> ............................... A 2 1 <br /> Character of soil to a depth of 3 feet: Sand 0 Silt L] Clay 0 Peat[:I Sandy Loom C] Clay Loam 0 <br /> Hardpan E] Adobe 0'_Fill M6teriol ............ If yes,type ............... ............ <br /> )Plot plan, showing size of lot, location of system in relation to:wells, buildings, etc, must be placed an reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage..pit permitted if pubilit,sewer Is available within 200 feet,) i <br /> PACKAGE TREATMENT SEPTIC TANK I ........ Liquid Depth .... ..................... <br /> Capacity II.. <br /> ex)P41.. Type -------------_---- Material.-A"-C......... No. Compartments ..... 1........ <br /> Distance. to nearest: Well ------------ ......................Foundation ...................... Prop. Line ................... <br /> LEACHING LINE No. of Lines -------_--------------- Length of each line....................... .... Total Length ........................7- <br /> V Box ..._:..... Type Filter'Material ....................Depth Filter Material .................................... <br /> Distance to nearest. Well ....................... Foundation -----_--_------ Property Line <br /> ................. ...--• <br /> SEEPAGE PIT Depth -------------------- Diameter ... Number ..--------------•-........... Rock Filled Yes 0 No 0 <br /> Water Table Depth ------------- -----------------------------------Rock Size .................. ...... <br /> Distance to nearest: Well ------------ .......................Foundation ........... Prop. Line ... .................77 <br /> REPAIR/ADDITION(Prev. Sanitation Permit# .................................. .......... Dote -_------­- .................l L <br /> Septic Tank (Specify Requirements) -_-----------------------_._..........:1..................................... ......­....... ......... <br /> Disposal Field (Specify Pequirementsl -- ----- 10-4 A a ....... ........... ............... <br /> -•-----------•------•---------------•-- -----­-------------­----------------------------------------------- <br /> -----------­-------------_-----------I-------------I——---------------­------- <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 Son Joaquin Local Health,,District. Home owner or )11cens <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 ---- --------------------------- O -4A <br /> ------------------------------------ ---------- Owner <br /> By ........ --litle .........r <br /> ........ <br /> ,(IfIerthan owner) <br /> % FOR DEPARTMENT r USE ONLY <br /> APPLICATION ACCEPTED By <br /> --------------------------:-:----- ------------------ ----------------------------- OAT .... .............t.. <br /> BUILDING PERMIT ISSUED --------------------- <br /> - -------- <br /> ......... ...DATE ------------------------I...... <br /> ADDITIONAL COMMENTS <br /> .......... ---------------------------------------I------------------ ----------- --------------------­-- ---------­-------- ---------------------------------_--1-------------- <br /> ---------------------------------- --------------------------------- - ---------- ----- -------------------------------------­­----------------------------------- <br /> - --------- ........ ............... <br /> --------- ------- ----------------------------------------*........ .................. <br /> Final Inspection by.,:::--;,;-- ---------------------------------•.............. ...Date .................. <br /> EH 13 2h 1-685k SAN JOAQUIN -LOCAL HEALTH DISTRICT <br /> �74 3M <br />