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i FOR FFIGE USE: FOR OFFICE USE: <br /> a APPLICATION FOR SANITATION PERMIT <br /> Permit No. <br /> (Complete,in Triplicatel <br /> •---------------- ----------- <br /> - Date Issued....3.'��_..- <br /> ................................. ........... This Permit Expires I.Year From Date Issued <br /> Application is hereby made to.the San Joaquin Local Health District for a:permit'to,construct and.install the work herein described. <br /> This application is made in compliance with County OrdinanceNo. 549 ond existing -Rules and Regulations:, <br /> JOB ADDRESS/LOCATION. --------CENSUS TRACT.. <br /> P - <br /> Owners Name.- hone...... <br /> Address------- --------- . ........:.... . ....City..... ............... ........... --- ----- --Zip---=--...... ... .....--... <br /> License ...._Phone-..(�.-• M—//��. <br /> { / l <br /> Contractor's Name. --.. .� 1 �i. ....... <br /> r Installation will serve: Residence Apartment House E] Commercial E] Trailer Court ElM tel ❑ Other. - ........... .......... <br /> Number of living units:................Number of bedrooms..-.19�.. Garbage Grinder--..........Lot Size------.--.......-.... .......---.-- ...... ..... .. .. <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 Loam E] <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 /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] Size------- ------------------••--------------------------`----Liquid Depth......... <br /> Capacity- . .. -----Type_----- Material----- ------ --------•-_No. Compartments ............... ---IV <br /> Distance to nearest: Well--------------- ............Foundation_---- ....Prop. Line--- ;^----- <br /> 1 ; <br /> LEACHING LINE [ ] No. of Lines......... -------------------Length of each line.------------- ---Total Length --------.....­.I <br /> D' Box -.-... . .Type-FiIter.Moferiai Depth Filter Material. .. ... _---- <br /> �. . <br /> Distanc&to nearest: Well.................... ---...Foundation----- .........Property Line---------.--_----------- <br /> SEEPAGE PIT [ ] Depth... Diameter.---.-- -----N m -- ---------- - <br /> ber- - - -•--------_--- Rock Filled Yes E] Na❑ <br /> � y <br /> Water Table Depth ---•-------------------- ......... .._ -----:....Rock Size...---..............-------------- - <br /> Distance to nearest: Well-------- <br /> =_ �..........is.Foundation--------- ------ ------- Prop. Line....... ------ ----- <br /> _ <br /> REPAIR ADDITION Prev. Sanitation Permit#.._....- Db#e, ..:.. -------- -----1 <br /> --- --:----- <br /> { Septic Tan pecify Requirements)--- . j <br /> . 6 ' <br /> Disposal Field (Specify Requirements).- -- . - <br /> I ............... F ....... ------------------ <br /> } " <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 Caunty <br /> Ordinances, State Laws, an'd Rules and Regulations of the San Joaquin Local Health District, Home owner or licensed agents <br /> signature certifies the following: <br /> "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner as <br /> to become subject to Workenon's ompensation-laws.-of California." - V <br /> I <br /> Signed-.- - -- ---- Owner <br /> ­ <br /> By----- ..........-- • .. .............. .......Title.`_ <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> [ APPLICATION - - -- DATE .... '� .'_1. ---.._....- <br /> ACCEPTED BY-- . .. .. <br /> DIVISION OF LAND NUMBEDATE.-....__----- --...... . <br /> - ----------------- ---------- --------- <br /> ADDITIONAL COMMENTS_--`-= ~- -���- .�.. ----- E- - ...... -------- ----------- <br /> ---------------•--------------- . ------- - - ------------•- - <br /> ------------. . . <br /> ------ <br /> Final-Inspection b -------------Date ��7 <br /> - - <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT f meq,` F6s sial 3M <br /> F }` <br />