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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> ------ Permit No: �-._5-5 5 <br /> (Complete in Triplicate) <br />� <br /> --------------------------------------------------------- Date )ssued ✓`--=-z-`�-=-�-v <br /> This Permit Ex Expires 1 Year From Date Issued <br /> Application is hereby made to the-.San Joaquin Local Health District for a pe'mit 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: i <br /> JOB ADDRESS/LOCATION // _ �_ -T 'f -------------=------ --------------CENSUS TRACT ---`0-7-----------•- <br /> T _ z .' S <br /> Owner's Name -------gc�-----------6 I-- j--- ------ ---1-�:-----------------------�- = ------Phone ----------------------------,--- <br /> Address —d - ----- ------�------- - ---- City <br /> ------------- <br /> Contractor's Name ........ -- - a � ----- <br /> Installation <br /> --- P1 .License # -/ - r_ Phone . <br /> Installation will serve: Residence ❑Apartment House❑ Commercial ❑Trailer Court ;❑ <br /> Motel ❑ Other ---------- ------ ------------ <br /> _- _.. =--- <br /> Number of living units:-- Number of bedrooms _ .Garbage Grinder ------------ Lot Size ---_---------------------_--------_--_-__- " <br /> Water Supply: Public System and name -----------------------------------•--------------------:--- -------------------------------------------.-----Private [ <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat E]'i Sandy Loam .d Clay Loam X <br /> Hardpan ❑ Adobe ❑ Fill Material If yes, 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 if public sewer is available within 200 feet,) I <br /> PACKAGE TREATMENT [ ] SEPTIIrCTANK:[� Size__�.X___IU___,_�C_ _.Z_ _______ Liquid Depth -- _ -------------- <br /> Capacity llpvc Type Material- -- No. Compartments - ............... �1 <br /> Distance to_ nearest: Well ------ ------------•---------Foundation -----10-r---------- Prop. Line ----S--f-- ---••----- <br /> LEACHING LINE (kill No. of Lines --_-o._ ._ - Length of each line.---l___- _�_.-_---- Tota[ Length -_1�o-t?---------------- <br /> 'D' Box ----- ----- Type Filter Material ---_$_R-------Depth Filter Material ---r�---------------------------- <br /> - <br /> ------- �F <br /> Distance to nearest: Well ------,�o_`_-----.-- Foundations ---_. �-- Property Line --- -----_----------- <br /> SEEPAGE PIT Depth ------c Diameter -- L-------- <br /> Number ----------;2------------- Rock Filled Yes No .C3 <br /> Water Table Depth -------------�------------------------------- <br /> Roc k Size �--------- <br /> Distance to nearest: Well -------------0-00__!--------------Foundation ----- - -------- Prop. Line <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date -------------------.--------------) <br /> Septic Tank (Specify Requirements) -------------------r -- --------------------------------------------- <br /> ----------------------------------------------- <br /> Disposal Field {Specify Requirements) ------------ ------------ -------------------------------------------------------------•--------------- <br /> -------------------------------------------------------------------------------------------------------------------------------------------------------------- --------------------------------- <br /> --------------------------------------------------------- - ----------------------------------------------------- ----------------- <br /> -Draw existing and required addition onre-verse 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 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 /> 24 <br /> Title ' <br /> By -------------------------------------------- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ----------------••---------------- ---------------------- DATE rS 'J``6' <br /> BUILDING PERMIT ISSUED ----- --- - --------------------------------------- <br /> -----•------ ---- ------------------------DATE --------------------------------------------- <br /> ADDITIONALCOMMENTS -- ---- ------------------------------------------------------------------------------ ----------------------- ------------------------------------- - ------ <br /> ----------------------------------------------------------------------------------------------------- <br /> ------- ------------------------ ------ ---- -------- ------------------------------------------------------------------- -----------------------^ ------------------------------------------- <br /> SAN <br /> --------- - - <br /> --------------------------------- ----- ---- ------- -------------------- ------------------------------- - ------------ <br /> Final Inspection by: -- - ----------Date j ------------------------ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'6B Rev. 5M <br />