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FOR`OFFICE USE: APPLICATION FOR SANITATION PERMIT //� f� <br /> ------------------------------------------------------- Permit No. .(�f P161 <br /> (Complete in Triplicate) ------_-- <br /> ----------------------------- This Permit Expires 1 Year From Date Issued Date Issued ..�_d7 �y <br /> Application is-hereby-made-to-the San Joaquin-Local'Healfl'District for a permit to construct and install the work herein <br /> described. This application is made in coriipli'ance with County Ordinance No. 549 and existing Rules and Regulations: <br /> �} `. <br /> JOB ADDRESS/LOC ION "�- --`----� ------ --- - r;liiff CENSUS TRACT ------- <br /> .a a - <br /> Owner's Name ------- -d-----------` -----------'-------------------- <br /> one ------------------------ <br /> Address ------- �F-- - `---/--�--- --------------- --------------- ---------- _. City - - - - - -- - ----- ------------------------------------- ------ <br /> Cantractor's Name t.d = ---------------License # � ,�' Phone ------------------------------ r <br /> F' Installation will serve: Residence Apartment House Commercial ❑Trailer Court ❑ <br /> Motel ❑ Other - ------------------------------------------ <br /> Number of living units:-- .------ Number of bedrooms -------- Grinder Lot Size �.?_.-. <br /> G � , <br /> �- X---/ -- ----------- <br /> Water Supply: Public System and name ----- ❑ w. <br /> _-_-.Private \ <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt:6 C y ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> • <br /> Hardpan ❑ Adobe,[M Fill Material ------------ If yes,type .._..--.__.-...._-..._--_- <br /> (Pl'ot 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 see ge pit permitted`public sewer is available within 200 feet,),', <br /> PACKAGE TREATMENT [ SEPTIC TANK IF Size_-- `_� _._1r _______________ Liquid Depth ._T_..._-.._-.._ --- <br /> Capacity )5E'_4____ .__ Type . -.. Material.- __ __ No. Compartments . �_______________ <br /> rr <br /> Distance to near t: Well .___.-.._.-<_�®______..__.Foundation .................. ... Prop. Line ._..__�_____....___ <br /> f i. I <br /> LEACHING LINE [ No. of Lines __ --------------- Length of each line'------�.d--------------- Total Length 1 .......... <br /> jv <br /> 'D' Box -_ - Type Filter Material _;,X---------Depth Filter Material -______�. ........--------------------- <br /> I i Distance <br /> ........r..._-_;Distance to nearest: Well ----- 0___-. -. Foundation -------/-,o Property Line ----_....__ .._1...... <br /> . <br /> ....__ Number ------ Rock Filled Yes No <br /> S i <br /> SEEPAGE PIT [ Depth ....-�_____ ____ Diameter - o�--------------� � <br /> Water Table Depth ------------!__p------------------------------%,Rock Size ----- �-�X <br /> Distance to nearest: Well ------------ �-.._..-_Foundation ------ ------- Prop. Line --------- ------------ <br /> REPAIR/ADDITION(Prev.:.Sanitation Permit# -------------------------------------------- Date ...--_---.._......._.__..._...__.-} <br /> SepticTank (Specify Requirements) -------- ----------------------------------------------------------- -------------------------------------- ••-•------------------------- <br /> 4 <br /> Disposal Field (Specify Requirements) --------—. — "-- <br /> -----------I------------------------------------------------------------------------------------------------------------------------------------ -- -----------------•----- ti <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 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 ubject to Workman's Compensation laws of California." <br /> Signed Title <br /> 4 Owner <br /> , ---------------------- ---------------------------------- <br /> By ` ' <br /> other Icin owner) 1 # <br /> a FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY__f_ ._ -7.- = -----------. DATE ...... ---------------- <br /> BUILDING PERMIT ISSUED .-- -- -_ ,p DATE ------------------------------------------- <br /> ADDITIONAL COMMENTS "' '.� .t .. .-+G= --- -------------------- ----- <br />}' ------------------------------- ------------------------------------------------------------------'---------------------------------------------`-------------------------------------------------- <br /> 1 ---------------------------------------- ' ----------------------------------------------------- <br /> ---------------------------------------- f/ <br /> ----------------------------------- '--:-- .__ _-------..,.,............-.----___..__._..._.-_ _-__.....-..-____.___.-__........-,-._--�_.___ <br /> i Final Inspection by: . .___ �T __ --Date --- <br /> --------------------- <br /> SAN JOAQUIN�LOCAL--HEALTH DISTRICT" <br /> E. H. 9 1-'6$ Rev. 5M <br />