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FOR OFFICE USE: <br /> 3 APPLICATION FOR SANITATION PERMIT <br /> -..__ <br /> _ _ _____ _ <br /> (Complete in Triplicate) Permit No. <br /> Rate issued <br /> This Permit Expires 1 Year From Date Issued <br /> -------------------- , <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:>519 nd existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION . ��1 (ll -- �. � �� TWO <br /> = 1' t- ~CENSUS TRACT ---- � <br /> Owner's Name •_ _-- 14Ne.11�� Phone ------------------------------------ ' <br /> r� -----------. City <br /> Address _u'S. ( r <br /> Contractor's Name --------5,T-�---------------------- - <br /> ----------------------------.License P h a n e 44 147, -�2--'7 ; <br /> Installation will serve: Residence pi-Apartment House,n Commercial ❑Trailer Court i❑ <br /> Motel ❑ Other ------------------------------------------- <br /> 1. <br /> Number of living units:---/------ Number of bedrooms ��------Garbage Grinder ------- ---- Lot Size ___ ___------- ---- ---------- <br /> ----------- <br /> Water <br /> Supply: Public System and name ---------------------------------•---------------------------- -- --- <br /> -------------------------------------- ---Private ❑ (.v <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay, ❑ Peat❑ Sandy Loam ❑ Clay Loam <br /> Hardpan ❑ Adobe e- 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,) r <br /> PACKAGE TREATMI NT SEPTIC TANK LA— Size_-- f r-r�-�!- ------- Liquid Depth _' ---------- <br /> Capacity /.2,0_0_eXiType Cn Material__��C No. Compartments 1:-2 <br /> to nearest: Well -.- ---17 __-1--e r- ----- Prop. Line -------- <br /> LEACHING LINE [Lj--YNo. of Lines __J�------------------ Length of each line----- d-----------.--- Total :Length A'-------------- <br /> 'D' Box _ i"1 Type Filter Material __ee!t -----Depth Filter MaterialI-/_---____---------------------------- <br /> Distance to nearest: Well ___j �..r------- Foundationf_d_l------- Property Line ___---:---- <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number ---------------------------- Rock Filled Yes ElNo <br /> Water Table Depth --------------------------------------- <br /> ---------Rock Size -------------------------------- <br /> 4 <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line --------------------- <br /> REPAIR/ADDITION(Prev, Sanitation Permit# ---------------------------------------- --- Date ----------------------------------) <br /> Septic Tank (Specify Requirements) ------------------- --------------------------------------------------------------------------------------- ----------------------------- <br /> Disposal Field (Specify Requirements) -_---------- ------------------------------- -•------- <br /> ------------- <br /> ----------------------------------------------------------- <br /> f <br /> -'---------------- ------------- ----- -- -------------- -- ---------------------------------------------------------------------------------------- <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 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 shall not employ any person in such manner <br /> as to beco%e subject to Workman's Compensation laws of California." <br /> Signed Owner <br /> Tit - --------------- ----------------------------------------------- <br /> By --------------- - -------------------- <br /> ------ ----- <br /> (If other than owner) <br /> FOR DEPARTMENT U5 ONLY <br /> APPLICATION ACCEPTED BY - U ---- - ---------- DATE <br /> BUILDINGPERMIT ISSUED - ------------------------------------------------ --- ------ ---------------------------DATE ------------------------------------------- <br /> ADDITIONALCOMMENTS -------------------------------------------------------------- -------------------------------- ----------------------------------------------------------------- <br /> ----------------- <br /> ------------------------------------------t <br /> ----------------------------------------------------------- ------------------------- <br /> --------------------------------------­- ­b-- ------A `--------------------------------------------------------------------------------------------------------------------------------------------•---- <br /> �'Wq <br /> Final Inspection by Date _--- <br /> -- ---- -- ---------------------------------------------------------------- <br /> 5AN JOAQUIIv LOCAL HEALTH DISTRICT <br /> I <br /> E. H. 9 1-'b8 Rev. 5M, <br />