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' APPLICATION FOR SANITATION PERMIT <br /> f" - <br /> Permit No. . 5..:.3l. <br /> ............. ........................................... , <br /> ........................................................ <br /> (CompleM In Triplicate) <br /> . <br /> This Permit Expires t Year from Doh Issued Date Issued -.S... ..... <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 .......�.Q ' --••....---..... .CENSUS TRACT ......................• - <br /> ... .. ...... ... ` Q <br /> Owner's Name .... <br /> .0111....._. .... .. ,�v,rje................................................. ..................Phone .?� .1.. .'r .......... <br /> Address p <br /> ��4I.0... ....rl✓......f, ..... "............................. <br /> ............. <br /> City ..................-•-•---•--•-•--................................ <br /> Contractor's Name ----.. ...............•----........................... •--•--------•..... 1 nse # ........................ Phone ............................... <br /> installation will serve, Residence❑Apartment House ComaWoTrailer Court ❑ <br /> Motel ❑Cather............................................ <br /> Number of living units:............ Number of bedrooms ----..------Garbage Grinder ............ Lot Size .- ............................ <br /> Water Supply: Public System and name ...................................._--------------------_....................................................Prlvatee <br /> Character of soil to a depth of 3 feet: Sand Slit❑ Clay .it Peat❑ Sandy Loam fit} Clay Loam ❑ <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 plated an reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted If public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT ( } SEPTIC WANK*] ......................... Liquid Depth .................. <br /> Capacity IPP.......... TypeAw.et. Material...�....... No. Compartments .. ............... <br /> Distance Yo nearest: Well ....A ........................Foundation ... ............... Prop. Line...,S.�........k9' <br /> LEACHING LINE No. of Lines .-1.................... Length of each line....iSP.................. Total Length .T................ <br /> 'D' Box .hv..... Type Filter Material --,I :.! ......Depth Filter Material ......................... <br /> Distance to nearest. Well ............... foundation .7�................ Properly Line S!t............... <br /> SEEP PIT f ) Depth Diameter ................ Number ............................ Rock Filled Yes ❑ No O� <br /> Water Table Depth ........................ .....................Rock Size... •• •--• ......_........ <br /> Distance to nearest: Well ........................................Foundation ..................... Prop. line .................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ............................................ Date ------------..--.-..-.---.--------} <br /> SepticTank ISpecify Requirements) ................................................... .........................................._..:..................:._............... . <br /> DisposalField (Specify Requirements) ----•--•----•........................•-----•....------.........--------......-----------••........................................ <br /> ------------------------------------------- ............................................................................................................................................. <br /> w; <br /> .................................................. --•-•------._...._........ ........----•-------•.......---................---------- <br /> (Draw existing and required addition on reverse side) <br /> 1 hereby certify that I have prepared this application and that the work will be done In accordance with Sar Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the Son Joaquin Local Health District. Home owner at 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 beca subje to o an`s Compensation laws of California." <br /> Signed . . ..... Owner <br /> By ................... -- -• ..- ........--- ....................................... Yitle ........................................................................ <br /> (If other than o nerl i <br /> FOR DEPARTMENT USE ONLY <br /> S <br /> • /II <br /> APPLICATION ACCENTED 8Y .�' .. .................................................................:...... DATE ......�.. -....s�:'.....:..:.............. <br /> . <br /> BUILDING PERMIT ISSUED DATE=................ ..•--..:......-.......... a <br /> ADDITIONALCOMMENTS ............. ..................................................................................................-.- ......................................... <br /> ------------ ............ ...... <br /> ...- . .... -.. ,.......- -. <br /> Final inspection by: ... ,��^Y� . Date . ..�. ..p.. .............. <br /> ......................••...---.... . ..... ................. .... <br /> EH 13 2h 1-68 fiov• SAN JOAQUIN LOCAL HEALTH DISTRICT $/7h jig <br />