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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT q <br /> (Complete in 7ripl(cate) Permit No. ...7 <br /> V d[, <br /> !.......................................... a This Permit Expires 1 Year From Date Issued Date Issued .. , <br /> 1SOS- «a <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the <br /> work here3r <br /> described. T.his,application is,made- in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> d.Z�3?�3=.ni.._rrcc,-mow. �ct� r _ <br /> J B ADDRESS/LOCA N �. .kj_ _-/ ![)f r... .. 1 ,�.M..CENSUS TRACT ._...................... <br /> i Owner's Name .....�./..... c c .. _ ....................... <br /> ................ <br /> Address ........ ..�:.Lc.. ... 7 one_... <br /> - <br /> ��:.......... .................: :..........Cif) � z . ......Phone .................................... <br /> Conirador's Name .... �+^�`.... ........License # �g� �°.? ":.. Phone ...................... <br /> Installation will serve: Residence ❑Apartmen use0 Commercial oTrailerCourt 0 <br /> Number <br /> Motel <br /> t <br /> Number of living units:............ ofbedrooms <br /> Garbage Grinder ............ Lot Size ..................................... .. <br /> Water Supply: Public System and name ...... ............ ...... ............ _.... --_.-..- ---- Private <br /> Character of soil to a depth of 3 feet: Sand]�ilt❑ Clay ❑ -Peat❑ Sandy Loam C] Gay Loam 0 <br /> Hardpan Adobe❑ Fill Material ............ If yes,type;,...­...................... <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 [ I SEPTICTANK{ ] Size.............. ............................... Liquid Depth .......................... <br /> Capacity ..................... Type .................... Material...................... No. Compartments <br /> ...................... <br /> Distance to nearest, Well ..................:......:..........Foundation .......... Prop. Line ...................... <br /> LEACHING LINE [ ] No. of Lines .....--. _............ Length of each line............................ Total length ............. .............. <br /> 'D' Box ........:... Type Filter Material ......................Depth Filter Material ...............'...... ' <br /> Distance to-nearest: Well ......:..........::.:... Foundation ...............:.........Property Line ...........`.._.......... <br /> SEEPAGE PIT [ j Depth ................... Diameter ............... Number ............................ Rock Filled Yes ❑ No <br /> Water Table Depth ................................................Rock Size :............................... <br /> Distance to nearest: Well ........................................Foundation ...._.......... .... Prop. Line ...----__..._ ........ <br /> REPAIR/ADDITION(Prew Sanitation Permit# .................................... ..::.. bate ..............................:.-.) <br /> Septic Tank (Specify Requirements) <br /> .............. ........ .. . .. <br /> ._................ 1i <br /> '.. . _ _ <br /> Dis osal Field (Specify Requirements) ... . .... .... <br /> .... .........•-•--•- ............. . I ........ <br /> ................ ............. ..................... .................................................................... ............................ <br /> (Draw existing and required addition on reverse side) S <br /> 1 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 /> "1 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 subject to Wo*Tan's Compensation laws'of California:" - <br /> Signed ............ .............. . .... . .. Owner <br /> r. < <br /> (If other than owner) ; <br /> ..... ....:!! 6.: <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY............. :1: ............................................................................. DATE .........�. �............ <br /> BUILDING PERMIT ISSUED ...... ...: .t:.... ..... .DATE ........:.... <br /> ADDITIONAL COMMENTS _-. . t�`�Y� """"' ""' <br /> ,p <br /> f ........................:.............:......................:.................................... <br /> ... ...::.....:.......................... <br /> .....•-----------......_-...:...................................................................... <br /> ........................................:................'.......:.......................:-----------......... ----•-•---------:........................................... . ..............._......... <br /> .................................................... ... <br /> Final Inspection by: .........................4M.........._...............; _ <br /> ..............._.. .......-.....--............... . .....Date . // .71....---............ <br /> SAN JOAQUIN r LOCAL' HEALTH DISTRICT <br />