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-- FOR- __OF- .FIC FICE USE- - ---------------: <br /> - - ---- - APPLICAk ON FOR SANITATION PERMIT <br /> Permit No. /�_`S <br /> (Complete in Triplicate) <br /> ------------------------------ <br /> Date Issued <br /> _ -_--___-------__--------_-___--___- This Permit Expires 1 Year From 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 Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION __ -_T`-_ -- 6L) ------ --CENSUS TRACT ----------------_____--: <br /> Owner's Name ..... ----- .P/ ---- -------------------------------------------------- -----„��`----- --Phone ------------------------ -•--------- <br /> Address --------------------- c ��� �-^�G / �[►--•--. City ---- "`^�`� <br /> Contractor's Name ---------- -- -- Phone <br /> ---�� K”" -- -d icense # �-7/ 7'1--- <br /> Installation will serve: Residence FtYApartment House❑ Commercial ❑Trailer Court ,❑ <br /> Motel ❑Other -------------------------------------------- <br /> Number of living units:---- --- Number of bedrooms _----__Garbagee Gprinder - ---- Lot Size ---_�r_ _ __--____ <br /> Water Supply: Public System and name ----------��..0 ---------------------------- --------------------------Private (0( <br /> Character of soil to a depth of 3 feet: Sand X Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe ❑ Fill Material _ If yes, type ---------------------------- <br /> (PI'ot pian, 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 <br /> Jf <br /> eet, <br /> PACKAGE TREATMENT SEPTIC TANK � Size__ -------- Liquid Depth ---------------- <br /> Capacity/.20C/"-4A- <br /> ---------------Capacity/.2mG /L-_ Type ��[xG MaterialNo. Compartments ,---------------- <br /> Distance to nearest: Well _--0 ", <br /> --- __r ------------ Prop. Line __ --_.________� <br /> LEACHING LINE ,k No. of Lines _-_-- ?------------- Length of each line------ed_-_- ------ Total Length _ � _- <br /> 'D' Box __/------ Type, Filter Material __- ----Depth Filter Material ---/,%�---_--_____.______________________ <br /> Distance to nearest: Well _._ (l ________ Foundation AP_0-______________ Property Line _47 -___......_. <br /> SEEPAGE PIT [Lt-'O' Depth -----1_�-------- Diameter -)--/---------- Number -------I-__--___----_-_ Rock Filled Yes 4 No iC <br /> Water Table Depth --- l=-----------------------------------------Rock Size ------------------------------ <br /> t Distance to nearest: Well ------.---------------------------------Foundation -------------------- Prop. Line ---------------------- <br /> REPAIR/ADDITION <br /> ___-___--______-____REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date _________________________________) <br /> SepticTank (Specify Requirements) -------------------------------------------------------------- -------------------------------------------------------------- <br /> Disposal Field (Specify Requirements) ------------------------------------------------------------- ------------------------------------------- --------------- <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, I shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed --------- -- - - ------------------------------------ Owner <br /> By -- -----------------'C=�r t -,`ems -_"_&_1------------------- Title -----4�_ -Iclh i <br /> ------------------------------------ <br /> (If other than owner) <br /> F(-A DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY __ ,,ex,-- - =-- -- ------ -- ----------------------------------------------. DATE ---� ------ ---------- <br /> BUILDINGPERMIT ISSUED --------------------------------------------------------------------------------------------------------DATE ------------------------------------------ <br /> ADDITIONALCOMMENTS ---------------------- -------------- ------------- ---------------------------------------------------------------------------------------------------- <br /> ------------------------------------------------------------------------------- -------- -------------------------------I------------------------------------------------------------------------------- <br /> ------------------------------------- - -------- --------------- ------------------- ---------------------------------------------------------------------------------------------------- <br /> - -------- ------ -- , <br /> --- --- --- -- ---- - -- - - --- - -- <br /> Final Inspection by: -- ----------------------------------------- Date <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F- H- 9 1-'68 Rev- 5M <br />