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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PLAIT 3-q 3y; <br /> -- - <br /> (Complete in Triplicate) Permit No. J----------------- <br /> ................................................... This Permit Expires 1 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 is made in compliance with County/<,),rdinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATIO -- -------_-..CENSUS TRACT ----_-------------------- <br /> Owner's Name --------- R% -Phone __._ <br /> Address � � /a < -- ...... City ... - <br /> . . ------•--•-------.---•-- <br /> Contractor's Name -------------------------------------------------------------------------------- ------License # ----------------------- Phone -------------------•---------- <br /> Installation will serve: Residence g48'�ppartment House-❑ Commercial ❑Trailer Court ;❑ <br /> Motel ❑Other ..... --- -----------------------•---- <br /> Number of living units: ....... Number of bedrooms 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 Loom gRtfClay Loam K;-- <br /> 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.) b, <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 .---_-____--_.--_---____-_ C <br /> Capacity --- - ------------- Type -------------------- Material---------------------- No. Compartments ----------•--••--•---- <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 /> WaterTable Depth ------------------------------------------------Rock Size -------------------•------------ <br /> Distance to nearest: Well ________________________________________Foundation -------------------- Prop. Line ---------------------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date __-__-___-_-__.__._____.______..__) <br /> Septic Tank (Specify Requirements) ------------------ ---------------------------------------- ------------- ------ ----------------------- <br /> Di s gsal .Field (Specify Requirement ) _____ . Q-_ � ----- - - [ --- ----- ----- - <br /> ----------- tG'z ` '�-�-- �Y/G'if � �-��; tL- <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 he performance of the work for which this permit is issued, I shall not employ any person in such manner <br /> as to become s ct to or 's Compensation laws of California." <br /> Signed :Y. ....J - - . ----------------------------------- Owner <br /> +.. By -------------- -------------- ------- ---------------------------------------- Title ---- - --- ------------------------------------- <br /> (If of than owner) <br /> FOR DEPARTMENT USE ONLY <br /> `' APPLICATION ACCEPTED BY .._. ._ -:�_:°: E.-:..__......_. DATE _` ._�..� _ <br /> _ •-- ----------- <br /> BUILDING PERMIT ISSUED ...----------------------------------.------.----•------------ -•-----------•----------------------------DATE <br /> ADDITIONALCOMMENTS -------------------------------•---•----------------------------------------- -------------•- --•--------------------------- ----•------------------- -------- <br /> ------------------------------------------------------------------------•--•---••-•--•-•--------------------------------------------------------------------------------------------------- ----------- <br /> - -------------------­ --- - -•--•------------------ -------------- ------------ --------------- ------- --- ! ; =r--------------m --- <br /> Final Inspection by: - = ----- - - -. ----------....Date <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br />