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P.I, <br /> FOR OFFICE USE: 5'x �� <br /> r+PPLICATION FOR SANITATION PER,vkiT <br /> ........ ---------------- ........... Permit No. <br /> (Complete in Triplicate) "7D " <br /> _____......... This Permit Expires 1 Year From Date Issued Date Issued -0.' ".7 <br /> FApplication is hereby made to the San Joaquin Local Health District- for a per to construct and install the work herein <br /> 1 described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> J v / �` _ <br />` JOB ADDRESS/LOCATI N ..__..1-. �` � `5:.... ..... .. . CENSUS TRACT <br /> Owner's Name ..._.. . G- .�_..- - Q "cam L_1 - ......................Phone <br /> 4 <br /> Address ................eP�. -C�4-� -- ------------- ---------------------•--. City / GCS ............_-................................. <br /> Contractor's Name ............... ------= ... -. ---------•--••-•---... .....License # __.._ -_- ------ Phone ----------------- <br /> Installation will serve: Residence Apartment House-❑ Commercial ❑Trailer Court <br /> Motel ❑Other ---------------------------Number ofliving units:..... ..._ Number of bedrooms .... 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 fl Clay Loam <br /> �. Hardpan ❑ Adobe ❑ Fill Material ------------ If yes,type --------------------------- <br /> i (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 TANK J Size................................................ Liquid Depth ....... ------W <br /> Capacity --------- .......... Type -................... Material-------------------._. No. Compartments ................ 1A <br /> Distance to nearest: Well ....................................Foundation ---------_........... Prop. Line ...................... <br /> LEACHING LINE [ ] No. of Lines ........................ Length of each line----------------------------- Total Length -----------------" <br /> r 'D' Box ------------ Type Filter Material ....................Depth Filter Material .-----..--..--"_.-_...._..-...._.----_.__.. <br /> Distance to nearest: Well ........................ Foundation Property Line ........................ <br /> FSEEPAGE PIT [ ) Depth __--_- Diameter ................. Number ---------.------_--_----_. Rock Filled Yes ❑ No ❑T <br /> Water Table Depth ---------------------------------------•--------Rock Size ................................ '7 <br /> Distance to nearest. Well ---------------------•----.........-.---Foundation -------.---_------ Prop. Line _....._..______.-... <br /> REPAIR/ADDITION(Prev. Sanitation Pe - <br /> �# .. Date ..................................) 7 <br /> Septic Tank {Specify Requirements) _. _ _ _____________ _______ <br /> 4 + Disposal Field (Specify Requirements) ---- L_ --------- -- ••----•---------�--- -------- <br /> --------------------------- --------------•-----• ------------------------------------------------ -------------- -- ----- <br /> -------------------------------------*----- <br /> ---------------------------------------------- ---- ------------------------------------------- <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, 1 shall not employ any person in such manner <br /> as to become su 'ect to Workman's Compensation laws of California." <br /> Signed ... - ---------------------------------- Owner <br /> (If other than 'owner) <br /> OR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -•--.. -- �r-"------ -------------- -- --•- DATE ..._...... ...7�.:.., <br /> BUILDING PERMIT ISSUED ..........•------- <br /> .............. <br /> ...------------- <br /> .-----------------------........11-11-.......:..............DATE _........... ................ ------------. <br /> ADDITIONAL COMMENTS -----------------------------------•---.........................-- .... .....•----..-..........................................._......."I. ------ <br /> ! , .-...........................I.........------------....... --•------------------- ---------------------------.........................................•--.------------------------------ <br /> ----------------------------------------------•- ------ ••-• •--------------------------- --------------------...----------- <br /> --------------------------- <br /> ----------- <br /> --••---•-....... <br /> ------------------------------------ ----- -- <br /> •----••--------------- ---------.--.---.---..---.-.--.--.---.-.--Final inspection by .----- Date <br /> - .• <br /> �- SAN JOAQUIN LOCAL HEALTH DISTRICT <br />