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FOR OFFICE USE: <br /> PLICATION FOR SANITATION PERMIT7�7 <br /> ------- Permit No. (. _-.. <br /> " ' '" (Complete in Triplicate) ---.--- <br /> -----------------------------------------_ -------------- This Permit Expires 1 Year from Date Issued <br /> Date Issued <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 /> JOB ADDRESS/LOCATION . aS .�ryCl�;uW1.--QR------------------------------------------------------------CENSUS TRACT -------------- ----• - <br /> Owner's Name Nr�% - v ---------------------------------------- ----------------------------- ----------Phone !:Lb 3 5$----------- <br /> Address ---------------------------------------- City --sS nk-- ------------------------ <br /> Contractor's Name ____- ' ------.License # :----- Phone .----__--_----------------- I <br /> Installation will serve: Residence Apartment House❑ Commercial []Trailer Court ;❑ <br /> a ' <br /> Motel F] Other - - -- -------------=-------------- <br /> Number of living units:__ ------ Number.of bedrooms -ra1--------Garbage Grinder .N01'CLot Size -----15OX l'(-" <br /> Water Supply: Public System and name --- AWF' �},ps'�tr- Private ❑ <br /> ----------------------------- -------------------------------------------------- --- <br /> Characfer of soil to a depth of 3 feet: Sand'❑ SiltO Clay ❑ Peat ❑ Sandy Loam ❑ Clay Loam '[] <br /> Hardpan M AdobeX 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 seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK:[ Size----------------------------- ------------ Liquid Depth ----.-------------- <br /> !Ex\S311ts Capacity --------------------- Type -------------------- Material---------------------- No. Compartments ---------------- t`I' <br /> Distance to nearest: Well ------------------------------------Foundation - -------------------- Prop, Line ---.------ _-------- <br /> LEACHING LINE [ ] No, of Lines ---------- ----- Length of each line---------------------------- Total Length .--__----------------- <br /> ����� 'D' Box ------------ Type Filter Material ---------------_---Depth Filter Material -------------------_------------------------ <br /> Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line. ------------------------ <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No 0 <br /> Water Table Depth ---------------------------------------=--------Rock Size -------------------------------- <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ------------ --------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) <br /> Septic Tank (Specify Requirements) --------- ------------------------------------------------------------------------------------------------------- <br /> DisPosal Field (Specify Requirements) - -- _ -- ------ � - .-1 i� � � _ - <br /> . / ------- ---------4---R!� ----------------------- <br /> ----------------- <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 <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 /> Signed ---------------------- ---- ------------------- --- -------------------------------------------- Owner <br /> By ------------------------------------- ------------- -------------------------------------- Title ----------------------- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY _Z-Al---- - -- DATE _ _ � . <br /> BUILDINGPERMIT ISSUED ------ ------------ ---- - - --- -------------------------------------------------- -------- ---.DATE ..----------------------------------------- <br /> ADDITIONAL COMMENTS . <br /> -- ---------- ----------- ------------------------------------- ------ <br /> ------- -------------------------- <br /> - <br /> - - ------------ ------ ----- - -- - ---------- -------- - - ----- --- ----fix, <br /> Final Inspection by: ------- -e ��-------------------------------- --------- -----------------------------Date <br /> 7SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'b8 Rev. 5M f <br />