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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT y <br /> .:_... <br /> (Complete in Triplicate) Permit No. <br /> ............................................. <br /> This Permit Expires 1 Year From Date Issued Date Issued .4. <br /> 7} <br /> Application is hereby made to the San Joaquin local Health District for. a permit to constructand install the work herein <br /> described. This application is made in compliance with /County Ordinance No. S49 and existing Rules and <br /> . Regulations- <br /> 'LOC <br /> lations: <br /> LOCTI . .JOB ADDRESS/ AN .......-- .....CENSUS TRACT ..........................•••-- <br /> Owner's Name --•- --- ---- . __ ....Phone .... -------- ....•.... ............ <br /> City .Address �� - ...--- <br /> License <br /> Contractor's Name _ .. . .... .,�. -. %e -• .�r�a'-p'/ .. Phone ,�� > .= �? <br /> Installation will serve: Residence Apartment House 0 Commercial ❑Troiler Court ❑ <br /> Motel ❑Other ................. ------------ ----------•- <br /> Number of becr2,-_---Garbage Grinder =- - Lot Size ... % �/ -------- -------•_ <br /> Number of living units:..../._. d oms _. --•••••• <br /> Water Supply: Public System and name <br /> ................. :..................... ...Private ❑ <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe Fill Material If yes, type ........... .........------ <br /> (Plot plan, showing size of lot, location of system in relation to well;,.buildings, etc. must be placed on reverse side.) <br /> p <br /> p <br /> p <br /> o: <br /> NEW INSTALLATION (Nseptic tank or seepage it permitted if public sewer is available within 200 feet,) <br /> ik � .. <br /> I PACKAGE TREATMENT I ] SEPTIC TANKSize. 0_..f..__ Liquid Depth ..-.4..... .............� <br /> Capacity/v�OO��Type��ateriol. .- o. Compartments ._ ............r/ <br /> Deis-ta�c/e/ to nearest: Well f-_. -1- ------Foundation .. i ._.'....-.. Prop. line .. �'-.- _..__ �} <br /> LEACHING LINEIX/�'4ro.4of Li ..._ .. . Length of each line ... Total Length ................------.._._. <br /> 'D' Box Type Filter Material ..............Depth Filter'Material ...-...._.__ ..._............... ----------- kA <br /> 4 <br /> ?--nonce to nearest: Well ........................ Foundation ......_.---.........:__ Property Line ----.-.......__......... <br /> StEPAGE PIT [ ] Depth . . ........ Diameter - Number. . ---_I- ------------------- Rock Filled Yes ❑ No ❑r <br />' Water Table Depth ................................................Rock Size ........._...---..;............ <br /> ... - <br /> Distance to nearest: Well ..__...-------------------•------------Foundation ------------- .... Prop. Line ----- --- ----- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ........ -_......._._..................... Date ------------.-----------------------1 <br /> Septic Tank (Specify Requirements) <br /> Disposal Field (Specify Requirements) --._...---_ -.- <br /> ----------------------------------------------- <br /> .. ---- <br /> ..----- <br /> .-............... <br /> •------------. <br /> i <br /> ............................-..._.. ................... .............---•.............._............. ------- -....---- <br /> (Drdw 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 Joaquln <br /> County Ordinances, State Laws, and Rules and Regulations of the Son 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, I shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed .:.. :. _.... ....---- <br /> .-------- <br /> ...------------------------------ --••------------- Owner <br /> 000' <br /> �_ ................. Title -._._.............._.. <br /> (if other than owner) <br /> By <br /> FOR DEPARTMENT UsONLV <br /> APPLICATION ACCEPTED BY . XJ.. ..... .......... DATE ........ ...._...__. <br /> BUILDING PERMIT ISSUED ......._........... .. ...................... ...... ................................. ...------ <br /> ---DATE ....... .................................. <br /> ADDITIONALCOMMENTS ...... ....... ------------...........------.__ --------------................. :--.-------- ............ .................................. <br /> ............... ............... ............___ --- -- -------------.... ..------ ------...-. ......---------------- ---....................... <br /> --------.......... <br /> I ...`... ,.... ----------------- - <br /> y <br /> Final Inspection by: ... .......__ -.Date <br /> -- ----- M .. --------- <br /> SAN JOAQUIN LOCAL HEALTH.,..DISTRICT­ <br /> ` 7172 3 �H <br /> 13 24 <br /> F i_ a� app_ �>U< <br />