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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> Permit No. .............. <br /> {Complete in Triplicate) <br /> i........................ _....._. .................. 7V <br /> ....................................... This Permit Expires T Year From Date Issued <br /> 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 i//s;; made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LO TION ..-- -- ...V-V-4...................................... TRACT` .....................:.:_: <br /> Owner's Name .. . �....... :..... �� .... _w _ . ....__ f Phone ................................... <br /> Address ................. . ..1!` .... .... __ .. ..... ...- -._.. City _. :�f....l. ...:.......................-................ <br /> Contractor's Name ..... _. _ ... . 4r_� ...... . i :. ........License # :��p�7 -.. Phone .............................. <br /> Installation will serve: Residence Apartment House Commercial [3Trailer Court I] � <br /> Motel ❑Other ...:----......------------- -----------------' <br /> Number of living units:....I------- Number of bedrooms ._S.-_..Garbage Grinder ...:.........Lot Size ... 4z:` --------------- <br /> Water Supply: Public System and name ---...--•------ ..--------------------=--------------------- --------------------;.1:... Private <br /> Character of soil to a depth of 3 feet: Sand]] Silt[j Clay E) Peat❑ Sandy Loam Clay Loam 0 �! <br /> Hardpan ❑ Adobe'Ej Fill Material --.----..... If yes,type ............................ <br /> (Plot plan, showing size of lot, location of. system in relation to.wells, buildings, etc. musebe .placed on reverse side.) <br /> NEW INSTALLATION: {No septic tank or seepage pit permitted_- if public sewer,is available within 200 feet,) <br /> j PACKAGE TREATMENT [ ] SEPTIC TANK I ] Size__......................... ............... Liquid Depth .................... <br /> Capacity ..... --------- Type ................. Material._..---------------_- No. Compartments. -- .............:... <br /> Distance to nearest: Well ......................................Foundation ............,......... Prop:Line ...... .............. <br /> LEACHING LINE [ ] Na. of Lines ------------------- Length 'of each line:_}}.....-- ........._.Notal Length ---. --_---_------.__.-. <br /> 0 l F = <br /> D' Box ............. Type Filter Materidl J.........:....:::Depth Filter Material ------------------------------------- <br /> Distance to nearest: Well ...._ ......t:-Foundoflon— .............. Property Line ........................F <br /> 4 SEEPAGE PIT [ j Depth Diameter ...................Number...._........................ Rock-Filled Yes ❑ No ❑ <br /> { Water Table Depth.. ............. .................Rock Size .........,--_-- .r:.--.... <br /> j,. J <br /> Distance to nearest: Well ........................................Foundation ._.............. Prop. Line ................. <br /> ` REPAIR/ADDITION{Prev. Sanitation Permit+# <br /> ............................................ bate -----...... ....-•-•----- .)� <br /> Septic Tank (Specify Requirements) -----................................................................................... <br /> Y ,. ...................7----------------- F <br /> Disposal Field (Specify Requirements) ._ _.. _... ... _ <br /> ,S .............•---•----------............. .__.......------------..__. <br /> =--------_- ----- --------------------- ................1­1---------------- ......------------..._........... <br /> (Draw existing and required addition on reverse side) <br /> 1 hereby certify that I have prepared this application and.•thaf the workjwill be done in accordance with San Joaquin-4- <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 <br /> ollowing:'--"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 /> s as to become subject to Workman" pensation laws of California."' <br /> Signed ............. ........-------------- -••--.• --- OwnerDer.. <br /> - Title .b '`..._.._.._....-•................................ <br /> (If other than owner) L <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ... ...... ..:...............:........................ ..... DATE ./ ._'../�. :�� ...-----•-----.... <br /> BUILDINGPERMIT ISSUED ....-...................................:....•-•--------=---:.................::=-......--:---•.._.......DATE .......................... ................. <br /> ADDITIONALCOMMENTS ----...:----...............................................................................•--.......... <br /> -••---•.................................... ........... y....._..:_._.�_.._._................... -•-----........:..__........._._.._...............................- .........._..._................... <br /> ----------------•-----••----- • <br /> _.....:........:..::�_ ........................ <br /> 00 <br /> Final Inspection by: ...:.. '� r. . -•---....---•--...... ..................................Date._...�.�.�`..,_...._.__._...--- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H.I 3 241-'68 Rev. 5M '� 7/72 3 M <br />