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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> ............................... ......... Permit No. ..................... <br /> (Complete in Triplicate) <br /> ...................... ............................. <br /> Date Issued <br /> This Permit Permit Expires 1 Year From Onto Issued <br /> 99 S <br /> Application is hereby made to the San Joaquin Local Health-District—for a" permit to construct and install the work herein <br /> 27 <br /> described. This application is made in compliance with County Ordinance No. 549 and existi g Rules d Regulations <br /> v*/ <br /> ..................CENSUS TRACT ... .` 4.�! .� <br /> JOB ADDRESS/LOCATION ..!�n.!:!_.__: - .. lwy----•-••••- . <br /> Owner's Name -- cE..fr_c...�i`n.._1/.�1.P ................. --._....------ ..................Phone ...... <br /> 3 ...._.....Address ... ��r� /._ •---.... City •--_._.-•-- <br /> �n <br /> Contractor's NameT J __.— . ..— .. _ icense # _.._.. , ..-- .._... Phone .............................. <br /> Installation wili-serve: "-Residence Apartment House C❑ Commercial ❑Trailer Court 0 <br /> Motel ❑Other ------- ------ ••-•-•------ <br /> Number of living units:............ Number of bedrooms ............Garbage Grinder -__..___-___ Lot Size .._� . .. ••••. <br /> Water Supply: Public System and name ...--- •---------------------•-- --.--------------------------------------.- -------------------- ........Private ❑r_ <br /> Character of soil to a depth of 3 feet: Sand❑ .Silt❑ Clay eat❑ Sandy Loam ❑ Cloy Loam 0 <br /> .Hardpan Adobe ❑ Fill Material ............ If yes,type ............................ <br /> (Plot plan, showing size of lot, locdtion of system .in relation to wells, buildings, etc. must be placed on reverse side.{ � <br /> NEW INSTALLATION: INo septic tank or seepage pit permitted if public sewer is available within 200 feet,) t1l <br /> PACKAGE TREATMENT-,[-I SEPTIC-T-ANK._f ] Size.......................................... Liquid Depth ..-------_-_-.-._.------ Ci <br /> Capacity ----r............... Type .................... Material...................... No. Compartments •---- ................ <br /> Distance to nearest: Well -..................:........•.........Foundation ........-........_-_-- Prop. Line ................... y ' <br /> LEACHING LINE [ 3 No. of Lines ..-----___............... Length of each line----------I.................. Total Length ........................... <br /> i r . <br /> 'D' Box ............ Type Filter Material .................:..Depth Filter Material ........................................ <br /> Distance.to nearest: Well ................`. :_"Foundation ........................ Property Line ---__.__ ............... <br /> SEEPAGE PIT I j Depth ._..__-_.._.....__- Diameter Number ............................ Rock Filled Yes [3 No <br /> Water Table Dep#h ' <br /> ------------- �_.........................._.....Rock Size ------._....-•-•--•---••-------- (Y? <br /> Distance to nearest: Well's'.....4................................Foundation --------_.--•....... Prop. Line _-------_----__-- r <br /> REPAIR/ADDITION(Prev. Sanitation'Permit# ---•---•..---- ------.......-............... Date ..................................11 <br /> Septic Tank (Specify Requirements) ---•----------------- --•---------- ........ <br /> .. • --------/-------........----_-•_. - ----_..-.................. <br /> Disposal Field {Specify Requirements) ..... <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 Rcen- <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 /> Y <br /> By ....................................................•-----------•---................----------_------- Title ......._...----.._._....._.._...._.._._._.-----...__............_...---• <br /> 4 (If other than owner) <br /> I FOR DEPARTMENT USE ONLY <br /> 92 1 <br />` APPLICATION ACCEPTED BY ....... .. ... : _----•---....-•-•-•------ ---------••- ...................... DATE .._�.— _'�_Y.........--•---..-. <br /> BUILDINGPERMIT ISSUED ......... ......................................................... ...... .................. •......._.._DATE .................. <br /> ADDITIONALCOMMENTS ------------------•--....---•-•-------•-----------------•----•-------------•----........._._...-----_..............---------...-_.:------------ _.......... <br /> ------------------------------•---..._--•----•---.......•--- <br /> ------- ..................................-------_---_-------.____._ .---...---_._._.._......._..___-------._...-•-•---..._._.._.__..._.........------•---•-......---___... <br /> ----------------------------------- -- --- ----------••---•-- <br /> Final Inspection by: ---- ---- ------------------ ----.---------._._.......... --- Date ..��:. 7�---_..._._.....----- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 71723 ,5 <br />