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f <br /> F R OFFICE USE: {� APPLICATION FOR SANITATION PERMIT <br /> ----- 3- - /--- Permit No. <br /> (Complete in Triplicate) <br /> 611--V _ <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 per 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 /> ) <br /> JOB ADDRESS/LOCATION rA --------------- -----------------------CENSUS TRACT --------------•----------- <br /> Owner's Name ----1��-- e149-49---------------------------- --------------- --- ----- Phone-------------------------------•----- <br /> Address ___ __ <br /> `��-------------- ------------------------------------------------------- City -- <br /> f <br /> Contractor's Name ---�-- r10-- /_ -------------------------=--------License 4 x __ Phone 0e�` . .. <br />{ Installation will serve: Residence [Apartment House❑ Commercial:❑Trailer Court ❑ <br />! k. . Motel ❑ Other ------------------------------------ --- ,fig <br /> Number of living units:.... Number of bedrooms - -____Garbage Grinder 4'VI - Lot Size ___ ,- --_ <br /> i Water Supply: Public System and name --------------------------------------------------------------------------------------------------------------Private <br /> ` <br /> Character of soil to a depth of 3 feet: Sand b Silt 0 Clay ❑ Peat❑ Sandy'Loam ,0 Clay Loam` <br /> Hardpan ❑ Adobe '❑ Fill Material ------------ If yes, type ____-_____-_______________ <br /> (Plot plan, showingsizeof 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,} V <br /> PACKAGE TREATMENT [ ] SEPTIC TANK{ ] Size------------------------------------------------ Liquid Depth --------------------,-...- <br /> Capacity ------- ------------ Type -------------------- Material-------- ------------- No.. Compartments ....... -------------- <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 [ ] z Depth -------------------- Diameter ________________ Number ---------------------------- Rock Filled Yes ❑ No <br /> Water Table Depth ------------------------------------- -------Rock Size -------------------------------- <br /> Distance to nearest: Well ----------------------------------------Foundation --------------_- --- Prop. Line _------.--------•__-.. <br /> REPAIR/ADDITION(Prev. Sanitation Permit# __________________________________________ Date ________-_-___--___-_____--___-_.-) <br /> SeptiCTank (Specify Requirements) - --------- _ -----------------•- --------------------------- <br /> ----- - ---- <br /> a <br /> Disposal Field (Specify Requirements) ----- 1 -----=-- � ------- , 1 --- ---------------- <br /> ' <br />' c---// -- ----- - ----------------------------------------- <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 Regulaf-ions 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-Compensatio ws of California." <br /> Signed ----------------------- ------ --------- -------------- - - Owner <br /> BY ---------------------------- --- --- -- `= Zitie / "' �- D---------------------- - <br /> (if <br /> -------------------- - <br /> (If oth an owner} <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY . - - DATE lC "'��---------------- <br /> BUILDING PERMIT ISSUED ----------------------------------------------------- --DATE" ---------------------------------------- <br /> ADDITIONAL <br /> ------------.----• --- <br /> ADDITIONALCOMMENTS --------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> --------------------------------- <br /> - --------------------------------------------------------------------------------------------------------------------------------------------------------------------•------------ ----------- <br /> G - - <br /> -�,------- <br /> Final Inspection by: ____--- _ --`- - Date __ -- ~. '---_- ------- <br /> ----------------------------------- ----------------------------------------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'b8 Rev. 5M f <br />