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FOR OFFICE USE: - <br /> APPLICATION FOR SANITATION PERMIT <br /> - <br /> ........................... .. - Permit No. ...7 : <br /> (Complete in Triplicate) ..y� <br /> ....3 <br /> ............................................ <br /> This Permit Expires 1 Year From Date Issued Date Issued .................... <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 /> : <br /> I JOB ADDRESS/LOCATION .../..,G .. •-----•../..l`�:�...............................CENSUS TRACT .:::...:......:........... <br /> �- Owner's Name .-- • . -- -- ....... . . . . ........... ..................I............. Phone .... ' <br /> v2 ;, <br /> Address _- .�. . - ..C.��.:. .... ............ ............. .. .. . City - ........ --•..........--•••---••--...._.__................--•----•--••-- <br /> Can#ractar's Name ""'" `` <br /> __ .:............... - ``.License # 13�cPy'Phone ....... <br /> Installation will serve: Residence (�Aportment House 0-Commercial ❑Trailer Court:, 0 <br /> Motel ❑Other ....:...... ....:........................... <br /> Number of living units:...... Number of bedrooms ...Garbage Grinder ............ Lot Size ...................... .:................ <br /> d Water Supply: Public System and name .......................... .... .._....---_ .................................................Private ❑� <br /> Character of soil to a depth of 3 feet: Sand n Slit E] ❑ Peat Sandy loam 0 Clay Loam ,v <br />' Hardpan ❑ Adobe Fill Materia# ............ If yes;type ............---------------- <br /> (Piot plan, showing size of lot,.location-of.-system in relation to wells,-buildings, etc. must be placed. on reverse side.j <br /> + S <br /> NEW INSTALLATION: (No septic tank or see.page•pit permitted if public sewer is available,within 200 feet,) , <br /> r PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] Size................................................ Liquid Depth ......_......_ ........... <br /> Capacity ------ ------------- Type -- -•--- •••... Material---------------------- No.' Compartments , .....----..........` <br /> 4. . . - , <br /> Distance to nearest: Well ................. -_.:.........Foundation .....:.:.............._ Prop. Line'..._.._...............J <br /> LEACHING LINE [ ] No. of Lines ------------------------ Length of each line _.... ......... Total Length. _._._'-..__................. <br /> I <br /> '..Depth 'Filter Material .__..V1 D' Box � �" Type Filter Material '- <br /> Distance to:nearest: Well ....................... Foundation ............._..:_:.__: Property Line ..._.._._.-- <br /> SEEPAGE PIT' [ j . Depth Diameter .--...... Number ,-..-..:....:............ .... Rock Filled Yes 0 No C]Z <br /> Water Table Depth......--............................. <br /> ..Rock Size ................... <br /> Distance to nearest Well ...Foundation ..................... Prop Line _ ........... <br /> kREPAIR/ADDITION(Prev. Sonitation'Permit# ............................................. ate ....................................) <br /> tSeptic Tank (Specify Requirements) ..:......:......:... .. ......--..............__...._......_... <br /> .�...:. ... ..... <br /> Disposal Field (S ecify :Requirements -•• -- • ...- -_ f <br /> .._...------ -�,�2_ .. .. ........... .................. .....--•- ----...---..__.....-----._......._._.. <br /> ........................... .............................................. ...... .... ... ---- --....---. .._......_.... -•--.......... <br /> {Draw existing and required addition:on reverse side) 1 „ <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 ahr� <br /> d•Regulations of the San Joaquin Local Health District. Home owneor licen- <br /> sed agents signature certifies the following. .. ._ - <br /> "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner <br /> as to become subject to Work �s Compensation laws of California." <br /> rVV} <br /> 'Signed - - = _ <br /> By ................................... ....'. .... . =. _ . Title .1 --------•...... . ....: . ...... <br /> (If <br /> other than:ownerl <br /> I FOR DEPARTMENT USE ONLY <br /> t. APPLICATION ACCEPTED 9Y ._.....-........ .........:....•-=----....._........... ... - :.. DATE :..lo'_/`�..�3.......---... <br /> BUILDINGPERMIT ISSUED ........................................._.................:: .......-. ---= --- -.......:....:.....:...DATE -------------------------------------------- <br /> ADDITIONAL <br /> --•-•--•--------- ---------------- <br /> ADDITIONAL COMMENTS ............................: <br /> ... :.. ---•--------•-•--_.....................•--•--•---- --•---------....------------. --...._..........._ <br /> i <br /> i ;_._ ......................... t .................................... . ........................ <br /> ................... <br /> ..........:............ . ............... <br /> .......... . .:.. .......-----------------.............................. . .........•••-•..R_ .. .......... - <br /> Final Inspection by: --------- --...._.......` Date �_. 0. 3............... <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> I <br />{, g u 13 24 ,_-In De.. z,u 7/773 .4 <br />