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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> . r Permit No. ..�3.'�� SI <br /> (Complete In Triplicate) <br /> This Permit Expires 1 Year From Date Issued Date Issued ........�..--_..... <br /> t....................................................... P <br /> i <br /> 4 <br /> Application is hereby made to the San Joaquin Local Health District for a,.per,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: <br /> k <br /> f --�"..���.............................. <br /> JOB ADDRESS/LOCATION �����-- ,.(._-•,� ..............CENSUS TRACT .......:.....:...::.-..... <br /> iOwners Name .... �� .- /� ..... .... .................................................... Phare ......-.......... <br /> Address f City a.�✓Qrf7 <br /> Contractor's Name ..-.-. -. .��---. 1 0/ -- ----":......••......................License #c Phone <br /> Installation will serve: Residence (Apartment.,House❑ Commercial ❑Trailer Court ❑ <br /> MotelF1Other..............'-•----•------•••--.............................. 'e <br /> Number of living units:.-/----- Number of bedroom`sc_ ... f.. , <br /> .- Garbage Grinder a��'.-::_ri tat Size A,,(������.......... ...... <br /> Water Supply: Public System and name --=-------------------------}----•- ............................................... ..........................Private <br /> Character of soil to a depth of 3/feet: Sand=j>,_ Silt E3 Clay ,❑ Peat C] 'Sandy Loam fl Clay Loom C] <br /> Hardpan ❑ Adobe Fill Material ............ If yes,type ............................ <br /> (Plot plan, showing size f lot, location of system in relation to wells,_buildings,..etc:..must.,be placed on_ reverse side.) <br /> NEW INSTALLATION: JNo septic tank or seepage pit permitted If public sewer is available within 200 feet,► <br /> PACKAGE TREATMENT' ( ] SEPTIC TANK t ] Size................................................ Liquid Depth .............................. <br /> I ^. Capacity ...-----........_... Type ----•............... Material ---..........•-- No. Compartments ....�..........._.� <br /> 4 - <br /> Distance to nea`resh Well—.................•--••.---..'.•------Foundation ...................... Prop. Line .................... d <br /> LEACHING LINE ; [ ) No. of Lines ..... _ Length of each line-----------------------_-_ Total length .......................... <br /> ' 'D' Box Type Filter Material .Depth Filter Materia) <br /> Distance to nearest: Well ...... ................. Foundation ........_... ........... Property Line .............. <br /> SEEPAGE PIT f j Depth .._................ Diameter ................ Numb r"".-:::- _.:...:::.:. Rock".Filled—Yes ❑ No 0 <br /> �. Water Table Depth ..................................------........Rock Size -------------••--............... <br /> Distance to nearest: Well ------------•-•--•--••--::..-•-...---..Foundation .................... Prop. Line ---• ............... <br /> E AIR/ADDITCON(Prev. Sanitation Permit# Date ) _ ] <br /> ................. ...... }� <br /> `Septic Tank (specify Requirements) .... ........, _..................._............ <br /> ... ._ 6 <br /> �/1,r 'C.Z .................. <br /> Disposal Field (Specify Requirements) .. -- . -- - � �-- <br /> f' r <br /> .....--••-----------------------•---....------------.--- -..--•-------••-------------•-----••-•----•----------.. . - ...................... <br /> ,h (Draw existing and required addition on reverse side) <br /> h 3 <br /> t I hereby certify that I have preparedlhis applicafiion land lhaF the work'will-Ii done in accordance with�San:,'Joaquin <br /> '.County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Hoene owner orkIiien- . <br /> sed agents signature certifies the following: <br /> 'q 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 /> By ---•- •.................. . ... . .- •-•--......................... Title Ad;; -�-- --- .....,-...... ............................ <br /> (If r than owner) <br /> FPR DEP TMIT USE ONLY <br /> APPLICATION ACCEPTED BY ..... ............................... DATE ..._. ..... . <br /> BUILDING PERMIT ISSUED........................ ..................................................................................DATE -------------•----•---•------------._------ <br /> ADDITIONAL COMMENTS ..................... <br /> ------------------------ <br /> ... .................•-------•-.----•----••-•-------.....---••.... . ... ------•---•• ` ................................................................................................... <br /> ... <br /> ................................... ----- ----- /.. ........--••--....--•---•--••-•................ <br /> Final Inspection by: .. ................................... .Dat :. r... <br /> SAN:JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H.13 24 1-'68 Rev: 5M . - - <br />