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FOR OFFICEtUSE' - <br /> APPLICATION FOR SANITATION PERNIRT Permit <br /> (Complete In Triplicate) hlb: •- S- <br /> 7 <br /> This Permit Expires ? Year from bate Issued Oats Issued .If:.. <br /> ............. ......._..._.._............._.. i <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 /> d <br /> JOB ADDRESS/LOCATi .._ ..... 0 - i.. .+� ! .E:�! 4'.CENSUS TRACT .......................... <br /> Owner's Name -............. . ._t.+�ye.��.. ` <br /> + t:............ .........Phone <br /> .-..' .. ..... city ........... .p D .,,£..••• ., <br /> Address <br /> Contractor's Name —I�/VT. . '� it � �� ....n�r-•....................license 4 ... Phone .............................. <br /> installation will serve: Residence Q Apartment House f] Commercial ]Trailer Court C <br /> • Motel Q Other............................................ <br /> Number of livingunits .._ Number of bedrooms Garbage Grinder - lot Size <br /> _. .a .................. <br /> - <br /> `,,W,ofirfiSupply. Public System and name --------------------- .................................._-....................................................Private <br /> ,® ! <br /> .Character of soil to a depth of 3 feet: Sand ffi Silt[] . Clay Q Peat.Q Sandy loam ❑ Clay Loam Q <br /> " Hardpan Q Adobe 0 Fill Material .........--- Ifyes,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 !f-public sewer is available within 200 feet,} <br /> PACKAGE TREATMENT [ SEPTIC TANK ] . ; Sine- ::._� � Liquid Depth .............:............. <br /> .. <br /> Capacity _11Type ... s ..... Material............. . ...".No. Compartments ...... ......... oQ { <br /> Distance to nearest: Well -------...........:.................Foundatia .--- ............. Prop. Line ......... <br /> f <br /> LEACHING LINE ( j No. of lines .__._r ..�;. ..__- Length of each line.....r .'....f.....,__. Total Length ....r2__l'17 <br /> ............. <br /> B <br /> D <br /> . ox 1 'Type .Filter Material �-��-------Depth Filter Material ..I/!•o•d............................. <br /> Distance to nearest: Well ........................ Foundation ........................ Property Line ........................ ' <br /> SEEPAGE PIT O Depth ---- -------------- Diameter ---__-..••...... Number ............................ Rock Filled Yes Q No (3 <br /> Water Table Depth t ........Rock Size . <br /> Distance to nearest: Well .......................Foundation .................... Prop: Line .............. <br /> REPAIR/ADDITION(Prev. Sanitation Permit* ..- ..'...... ................. Date __._.t- ___.._ • . �. <br /> SepticTank (Specify Requirements) ...............•--.-------...------------------------------...--•---.......---••- ----•-- ................................................... <br /> • <br /> Disposal Field (Specify <br /> € -- ----- . . ----------- <br /> Requirements) ..... ............ r._....- , •, <br /> ...• <br /> -� (Draw existing and required addition on reverse side)'=p° <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance "h 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 /> Sign � ..._.. X7 <br /> - e / T / <br /> BY ......-•---------------- Jitle _.�Z.../Nci_ ............................ <br /> er.than ow er� <br /> FOR DEPARTMENT LISE ONLY <br /> APPLICATION ACCEPTED BY _ •-- --- ------•-.­-- DATE ............... >.........:t <br /> BUILDING PERMIT ISSUED _11...................................... ...................... ----------------------------------DATE ..................•---•-------............ <br /> .' <br /> ADDITIONAL COMMENTS --------------------• -• <br /> ........................................... ..----------- -------...-----.-. -. .................. <br /> ......... .......................... ------------------------ ------•----•---- --------------•-•• --------- ••-- -- ---"=- _. <br /> --------------------------------------- <br /> ---------------------------------------- ----------------------------------------- <br /> FinalInspection by: -•---------•• --------..............................•........ ................Date ..... ...t- ...... <br />` EH fl3 24 1-68 Rev. 5M SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M <br />