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FOR OFFICE USE: Ta <br /> APPLICATION FOR SANITATION PERMIT _ <br /> .............•• Permit NoZ,, -- I_:y <br /> (Complete in Triplicate) <br />........................................................ This Permit Expires 1 Year From Date Issued <br /> Dote 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 Mules and Regulations: <br /> J48 ADDRESS/LOCA ION :...... � � fJ �........ ..... ..................CENSUS TRACT .......................... <br /> Owner'sName ._. Ql.!1.�` ..., .........../.�r..�/�a•. --- ----------- ........................Phone .................................... <br /> Address ............. ............................ ......... City <br /> Contractor's Name .........5.d_f............................................. ---.....---.......License # ......................... Phone .............................. <br /> Installation will serve: Residence❑Apartment House <br /> J❑ Commercial ❑Trailer Court <br /> Motel -other --- .�r-.d C'/.( ...4.4?w--,!!------- <br /> Number of living-units:..__,(.___... Number of bedrooms __.A....Garbage Grinder ............ Lot Size ... ......... <br /> Water Supply: Public System and name ................ ............................................................-•...............................Private " <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ ' Peat❑ Sandy Loam ❑ Clay Loam ❑ - <br /> Hardpan)K' Adobe* Fill Material ----__- ---- if yes,type --------------_--------_- <br /> (Plot <br /> _.___.____................(Plot plan, showing size of lot, location ofsystem 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 TANK Size................................................ Liquid Depth .......................... 6 <br /> Capacity 1"i1. .�.- Type rC.C .`rl Material'._601�re�. No. Compartments � Pte....... . O <br /> -- <br /> Distance to nearest: Well ._.�� �- .... Foundation Prop. Line <br /> LEACHING LINE: No. of Lines d._�� - Total Length�` _. Length of each (ine...�� g ••,ldo .7`-----. O ; <br /> 'D' Box Type Filter Material C ...:..........Depth Filter Material 1 .e f ..... <br /> Distance to nearest: Well ..... Foundation _.--. Property Line .. ` .:. <br /> X�7�,,,y1- rr _ (" C3 ! <br /> SEEPAGE PIT � Depth _.�:� �f Diameter ...�..�✓....._._ Number .... ..._ <br /> .............. Rock Filled Yes No <br /> __. ......_..Rock Size <br /> meA, <br /> Water Table Depth --------� -- - ...--•----- -•---------------------------- _ . <br /> f -- <br /> Distance to nearest: Well -_->!-&:P)L...................Foundation .. 1. _..._ Prop. Line __-­-_----.-:� y � <br /> REPAIR/ADDITION(Prev. Sanitation Permit# _........._..:...........::............•__-. Date ..................................) C <br /> I <br /> Septic Tank (Specify Requirements) ................... <br /> .L..:.:....................................................-.—........................, -- ........-------------- <br /> Disposal Field (Specify Requirements) ............................. _.:-----------------------------------.................._.. ........................................... I <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 become subject to Workman's Compensation laws of California." <br /> Signed .... ... =. <br /> -. .. ............. Owner , <br /> By -.................. -- .................... ----.---------- ----- ............... Title _--_---------------.................................................. <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APi'LICATION`ACCEPTED BY ........ ._.. DATE ..... -•- z(,r............. <br /> BUftDWGPERMIT ISSUED .............-------- - ---------•-•-•----------------.._....------------------------------=--------•-- -DATI= _:............ ..................... <br /> ,AbbITIONAL COMMENTS .............................•------..............----............................................................ <br /> .................... ....... --•---------....... ..................•----------•------...:_....................................... <br /> ................................................................................._...................................._.... -.-.-.-.--.--.-.-- <br /> ----•---•------------------------ ......... ...... <br /> !�� 2 <br /> FinalInspection by: .. .............................--••--.................................Date ... .. ....... .__ ......--------------• <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br />