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FOR OFFICE USE: <br /> LICATION FOR SANITATION PER <br /> ........ ............ .......... ... ....... Permit No. <br /> (Complete in Triplicate} <br /> ......I............ .. This Permit Expires 1 Year From Date Issued <br /> F <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 /> F'�escribed. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION _ 5 E'_W��iU,._.Q� .�._� -�.�. .Wt.rs�+�..� ..CENSUS TRACT -------------------------- <br /> wner's Name ........ .......W. .........---....... ....... ...Phone .................................... <br /> �4ddress .-- .---.. ----------- City . .. . .. .. .... _. ... .. _.------------ --- <br /> .-•........ ... <br /> Contractor's Name �• . ..1 .. 5lE -_ �.�!�------.License # T`-' '- Phone �e_7_____ t <br /> Finstallation will serve: Residence ❑Apartment House 0 Commercial �l railer Court EJ i <br /> Motel ❑Other ---------------------` r <br /> umer of livingunits:.. Number of bedrooms ____..._____Garbo a Grinder .......... . lot Size -� f._ <br /> 9 .... ......... <br /> C�atebr Supply: Public System and name . • --•-- ------------------------------ ---- - --• . ---_--------- ----- •-- ...--------..Private f <br /> Character of soil to a depth of 3 feet. Sand F] Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay loam ❑ <br /> F Hardpan ❑ Adobe 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.) V <br /> FVEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> t PACKAGE TREATMENT I ] SEPTIC TANK+[ ) Size..._....... _ .. .... . Liquid Depth <br /> Capacity Type .�' °� _ Material.. No. Compartments _ <br /> Distance to nearest: Well �� r 1---------------...Foundation . &c 6._ - . Prop. line _ '..�_...-.... <br /> LEACHING LINENo. of Lines r <br /> [ ) f Length of each line .....,��_.. ... . . Total Length I.q'U...... <br /> ( 'D' Box Type Filter Material 1�1.... _�_._I -Depth Filter Material ... .............. <br /> Distance to nearest: Well ....... Foundation al ............ Property line <br /> EEPAGE PIT [ ) Depth a�S ...- -- Diameter --- . �.�.._ Number (. .. .... Rode Filled Yes No <br /> Water Table Depth ...... .....................Rock Size .............. <br /> Distance to nearest: Well ....-. .!_�` ....4`..................Foundation -.JQ.'_ Prop. Line _., ................ I <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ........ _._ ........... Date ...........................-.....) <br /> Septic Tank (Specify Requirements) - - - .._,............................:.......... ... <br /> Disposal Field {Specify Requirements) ......--•-------------------------------------------.-.-.-...--.-- .. .... <br /> . . ............ -- ---- ........ ........ .......... ...... ............. <br /> (Draw existing and required addition on reverse side) <br /> 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 Iicew <br /> ed agents signature certifies the following: <br /> �l 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 War an's Compensation laws of California." <br /> geed . .. . . .. .. ... . . ... . ........... .................. Owner <br /> �y <br /> Title kAIV I <br /> (If other than owner) i <br /> 1' I FOR EPARTMENT USE ONLY � <br /> Fj7kPLiCATION ACCEPTED BY . 'I. ... DATE . )`. .Z..... <br /> BUILDING PERMIT ISSUED :. - :-.. _ ............... .... ..... .. .. DATE _............_. <br /> ADDITIONAL COMMENTS .. ... . ..... . .. .... . ........ ..... :.........._....... <br /> t - ................./- ---. .- _ ... ... __. --.......... ............ ....... .......... ........... ..... ............................................... <br /> ..._.. <br /> ..................... <br /> . ...---- ...._..- <br /> inal Inspection 6y: = Date . � �----------•-•------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT +� <br />