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USE: <br /> FOR <br /> _. -._..-•- - .._ • •.OFFICE APPLICATION FOR SANITATION PERMIT <br /> IComplete in Triplicate) <br /> -, Permit No. ..�_ �`.�_.._. <br /> ......_...;. ........:_ n - .�._... _._..,.._....� <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'lapplicotion is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> 1 <br /> JOB ADDRESS/LOCATION .f.��..��..�.�.�.............. .. . .-..........._. ................-CENSI!$ TRACT ......... ................ <br /> Owner's Name -�.. ... <br /> ................................. ... ...........Phone ......... I......_ ...... <br /> Address . . ... ./-.v�/. . , ...._.. <br /> City .........,_........... ....... ..... ...... <br /> Contractor's Name ..... .............. ... /.lF' ...license # '3MrPhone ......:.......-............. <br /> .. i <br /> Installation will serve: Residence Apartment House CommerclaI OTrailer Court 0 <br /> Motel []Other <br /> Number of living units:...... Number of bedrooms _ _._-_Garbage Grinder ............ lot Size ............................................ <br /> Water Supply: Public System and name ......Private <br /> Character of soil to a depth of 3 feet: ` Sand 0 Silt 0 Clay ❑ Peat[3 Sandy loam ❑. Clay Loom a--~ <br /> Hardpan Q 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 seepage ,pit .permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT SEPTIC TAMC�� � r 1r � ....... Liquid. Depth ......`..�.. '....... i <br /> Capacity . Type�' �•.Material..- ,_- No. . Compartments .. -............. <br /> -- .._ <br /> Distance. to nearest: Well ----------�_o__1.................Foundation .....x.0............ Prop. Line ....fir.............. <br /> 6 <br /> LEACHING LIN€ [ No. of lines .... ------------ Length -of-each line--------- ... Total length _J..�.° ... 00 <br /> 'D' Box .....I----- Type Filter Material ......-'�..R.....Depth .Filter Material ........I_I._........................... � <br /> p. <br /> �! Distance to nearest: Well .... ------ Foundation ......1..0........ <br /> --__ Property Line ..._:$................ <br /> SEEPAGE PIT {)1/ Depth ----�-' _ _��_ Number ....._..�----_-_ � 0Z <br /> . .._. Diameter _..... Rack Filled Yes No <br /> H Water Table Depth ..............!_^4- _.__ .... Rock Size . <br /> ..�.l.. .�...X. ��.._._ <br /> .--••- - <br /> I 6Distance to nearest: Well ------- _b Q_____________________ Foundation ----L_q..r....... Prop. Line .5----•-.,:.......... <br /> REPAIR/ (ADDITION Priv. Sanitation Permit r#` ........... .......................... Date __................................I <br /> SepticTank {Specify Requirements) ---•----•------_ -------------------------------------------................................................................................. <br /> Disposal Field (Specify Req.uirementsl ...................... ........................ -------- ----------=.............................................. <br /> ......, <br /> -------- ----------- ----------­--- ...... ------------------------------------------------------------------------------------------------------------------------------------- ------------------- -- <br /> i <br /> -------.--------. 1---- -- - <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. Hence 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;l shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed ------------- •----•-- --------- -•---------- Owner <br /> �i --- - <br /> BY ---- - --------- -- -----•----------- - . ����1._`-�-------,.-.. .' _ _ Title _..,_- ....----... ._ <br /> (lf other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> DATE ... <br /> APPLICATION ACCEPTED BY ----: <br /> BUILDING PERMIT ISSUED'-.::----------------------------------------------------------------- *----------- ------:---.-�_DATE --------------_-__-,......-_..•...- <br /> ADDITIONALCOMMENTS ---•--- ------------------------------•_-_----•---.-__---.-.-------•--------.--. ------------- ------------------------- --------•--- -------- <br /> ............................................ ---•--------•-•- ---------- ... ... . .........................-.-....-.--------------- <br /> ------------------------------ <br /> Finalinspection.---------------------- --------• - - ----- ---......._.-.....---..-........ <br /> by �a :... •- --------------------------- ----------------•---------------- -._...-....------ ...:-._Date f ./8.�.�. -----...._.._... <br /> EH 13 22 1168 Rev. 5M SAN JOAQUIN LOCAL HEALTH DISTRICT 8/71; 3M <br />