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FOR OFFICE USE: T <br /> APPLICATION FOR SANITATION PERMIT <br /> T (ComPermit No: <br /> (Complete in Triplicate) ..............:r <br /> ......••.•. ................ This Permit Expires ] Year From Date Issued Date Issued <br /> Application is hereby made to the Son Joaquin Local'Health District for a permit to construct and install 4 work herein <br /> described. This application is made in compliance with County Ordinance No549 and existing Rules and Regulations.. <br /> r . sng <br /> . . <br /> r I <br /> f JOB ADDRESS/LOCATION aI• E.... .. -ra-r� // <br /> I � Y.9NSUS TRACT <br /> f Owner's Name ... !.. `• - ' 1.... �y. .......:.a . <br /> ��ei�..rrc�.............................:... ---•..Phone Z <br /> I Address __.... ::2-.1.C).. <br /> r --•--.. .._. r.(„l1... _. City <br /> Contractor's Name <br /> t .� .License #2s� <br /> '. .. Phone . 6' '�� <br /> i Installation will serve:- Residence ❑ Apartmentuse'❑ Commercial ❑Trailer Court 0 <br /> Ap <br /> c. <br /> ­'Motel ❑Other --- -- -- • -_ p-60te. <br /> Number of living units:...__:':.__ Number of bedrooms ..........__Garbage Grinder ___...__.._. Lot Size ......._._. _ <br /> E ..---•- ....... <br /> Water Supply: Public System and name Private <br /> Character of soil to a depth of 3 feet:; Sand E3Silt❑ Clay E] Pe' 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.) N <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200+feet,) <br /> PACKAGE TREATMENT r ` �u <br /> ( ] SEPTIC,TANK`j� <br /> ize----------- -------�._�.----•......._.... Liquid Depth ...�t,� ----., <br /> Capacity _f __..._ TYp® - ------••- •-'--_-. Materiai...Cc: No. Compartments 2-- <br /> ........... 4 <br /> Distance tol nearest: Well--= .- .t._ ..__•...Foundation...__!.f' Prop. Line .5.. f <br /> ` ..............- <br /> LEACHING LINE �Q No. of Lines f � � <br /> / Length of each line.__.. . --- . Total length c'.._.�.�............... <br /> Box .. S/'' Type Filter Material <br /> ...... ..... ....Depth Filter Materia! .....�.�. <br /> t r <br /> Distance to nearest: Well Q...... .._ Foundation ......... Property Line .. , f- <br /> SEEPAGE PIT aaepth .... '._..... Diameter~ 33`� Number ........ . ..... ......... Rock Filled Yes No <br /> —.--,_ <br /> Water Table',Depth f <br /> `.-- <br /> Rock Size .�... t ' <br /> Distance to nearest: Well .....1: .._.._._ Foundation ...l..e_ Pro Line r� <br /> -••••-----...._. --••- p• ---------•-- <br /> REPAIR/ADDITIONPrev. Sanitation Permit 9 <br /> ( ...........-.......................•............ Date ...................... <br /> Septic Tank (Specify Requirements)............................ <br /> ---- ..........-.............................I—...................................... <br /> _....._ .......... <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, andlRules and Regulations of the San Joaquin Local Health District. dome owner-or liven-, <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 .. .... Owner <br /> By ........... <br /> X1(1_....... .. --.. .. <br /> -•---•----- ,Title .............. <br /> . (I oth tan owner) - - �- -- -� - _- <br /> fi <br /> FOR D>rPARTMENT'USI:-ONLY <br /> APPLICATION ACCEPTED BY . __.. .� <br /> ................................•.. ..---•--••.........._...........•----.. .. DATE . ...._.�..._ <br /> BUILDING PERMIT ISSUED ......----- <br /> ADD TAL CO TS ...... M ..__... <br /> T- 4.LrC7y ' iG r� ,_ <br /> Final Inspection y ,��' •............... ....... - --- <br /> a- --....-- ----... _....n. <br /> STAN <br /> JOAQUJN LOCAL HEALTH DISTRICT <br /> l3 24 <br /> E. H._- 1.'68 Rev. 5M <br />