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FOR OFFICE USE- APPLICATION FOR SANITATION PERMIT Permit No. <br />...................................I......... ------- ... (Complete In Triplicate)._, <br /> Date Issued J................ <br /> ............... ...I......... <br /> This Permit Expires I Year From Date Issued <br /> ........ <br /> ical Health District for a permit to construct and install the work herein <br /> described. This application is <br /> Application is hereby made to the Son Joaquin made in compliance <br /> Loe with County Ordinance Na: 549 and existing Rules and Regulations- <br /> .......—............ <br /> ......CENSUS TRACT <br /> JOB ADDRESS/LOCATJQN .....Phone ............­.......... ........ <br /> Owner's Name ---------- -- - ....... ... ..... . ............. <br /> 1;-;5 ............ .............. <br /> 10, J <br /> Address .... ........ ......... ........ <br /> -3 Phone ...... ....................... I <br /> Contractor's Name ..--• .... ... ............. ........ # ap, i;. <br /> installation w.ill serve: Residence Apartment House f] Commercial'ElTraller Court 0 <br /> ther <br /> Motel 0O <br /> Number of living units:--!---- Number of bedrooms ge ....... <br /> Grinder ............. Lot Size <br /> ........Private <br /> Water Supply: Public System and name ---------------------------------­...----•-•...---.....---'--• <br /> ................................­.;-------- ............. ............................ <br /> Character of soil to. 'a depth of 3 feet. Sand t] Silt Q Clay 0 ' Peat 0 Sandy Loom Clay Loom 0 <br /> Hardpan ❑ Adobe 0 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 seep e pit permitted if public sewer is available within 200 feet) <br /> ....... Depth ... ................. <br /> PACKAGE TREATMENT SEPTIC T, Size...Y Liquid <br /> y Moterial..(.,e4 No. Compartments .- <br /> C <br /> .............. <br /> Capacity T r <br /> Prop, Line ...5i... .........--jr <br /> ...Foundation ..... <br /> Distance to nearest: Well .......... Total Length Aq.a ..........1�1 <br /> No. of Lines ......... <br /> LEACHING LINE [q/ .......... Length of each line. <br /> V Box ..../----- Type �Filter Material ....?;�'...Depth Filter Material ..../,%...............................­Im <br /> Well ...... Foundation .... Property Line .....:-�......... . <br /> Distance to nearest. fk4-,�- ------ ......... Rock Filled Yes 0 No <br /> SEEP.AGE PIT Depth .................. '.Diameter ................. Number ------------------- <br /> Water Table Depth ..:.............................................Rock Size -------..-.••............ <br /> Distance to nearest::Well :.--...----•------••-=-----------.......Foundation Line ...................... <br /> --------------- Prop. <br /> REPAIR/ADDITION(Prev. Sanitation Permit#-_•.-•-----•-••------••--•-------- <br /> Date ----------------------------------- <br /> 1 I <br /> --------- <br /> .......... ............11........... ................... <br /> Septic Tank (Specify.Requirements) ----------------------------------------------:1.-......... <br /> Disposal Field (Specify Requirements) ---------------------------- ...... ------------------------------------­.­...... <br /> •••------•--------•--.------­------I.............................. ........................ <br /> ---------------:-----­----­------- -------------- <br /> ----------------- .......................m................. <br /> ----------------------------------------------------------------------L------------------- ------•---•.........._I------------ <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 Son Joaquin Local .Health,District. Home.owner or 11I.Ce-n. <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 /> e ........I...................L.......... <br /> By ......................... .... ........ .... .... -------- Jitl <br /> ---- -------------------- ---------- ... <br /> (if other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> ... .. ........ .............. <br /> DATE <br /> APPLICATION ACCEPTED BY --- ----- ----- ---- ----- <br /> ------ ------------------------ DATE ........I........ -------- <br /> BUILDING PERMIT ISSUED .-------- - -------- •-•--•---•------------------------------------------ ----------------- ---­........ ......................... <br /> ADDITIONALCOMMENTS ­----------------- ------ ...... -------­----­--- -------------------- ............. ------------------------------------- <br /> ---- ----------- --------------- -----------------I----------------------------------------------- --------------- <br /> ---------------------------------­........ ----------- ------ ....... ............ ...... <br /> ttl-� <br /> Final Inspection by: �.......... ............ <br /> ........ ................. <br /> - - --------------------- --------*............ <br /> --------------- ------------------- ----- ---- ..........Date <br /> ---------------------------------------- .................. <br /> DISTRICT 8/7h 3M <br /> EH 13 2L 1-69 3 SAN JOAQUIN LOCAL HEALTH <br />