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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> `----------- ------------------- -- ------------ <br /> (Complete in Triplicate) Permit No. .-�7i G._____ <br /> ------ This Permit Expires 1 Year From Date Issued 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 sting Rules and Regulations: <br /> 60 JOB ADDRESS/LOCATION "- .CENSUS TRACT __- __. -______ <br /> Phone J � . <br /> Owner's Name - -r��1--C`'il �--�-�_f`O��h?,/�'--------- I----------------------------------------------------- ����.--------------••--- <br /> Address -r+�� ---------------------------------------------­­ City ------------ ------------------------------------------------- ---- -•-•---- <br /> Contractor's Name -------------------------------------- License # ------------------------ Phone <br /> Installation will serve: Residence ER_9�partment House❑ Commercial ❑Trailer Court l❑ <br /> Motel ❑Other ------------------------------------------ <br /> Number of living units:-„/-----:-_Number:of .bedrooms_=�3:--__Garbage Grinder ---- ------- Lot Size ------ <br /> ........ . <br /> Water Supply: Public System and name ------------------------------------------------------------------------------ -------•-------•---------------Private. <br /> Character of soil.to a depth of 3 feet: Sand'R., Silt[] Clay .❑ Peat❑ Sandy Loam -0':XClay Loam <br /> Hardpan ❑ Adobe ❑ Fill Material ------------ If yes, type ----------------------------- -- <br /> (Plot <br /> (Plot plan, showing size of lot, location of system„in.relation,totwells, buildings, etc. must ;b`e' plbced on reverse side.) <br /> NEW INSTALLATION: {No septic tank or seepage pit permitted if public sewer is available within 200 f?et,l. <br /> PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] :; c--Size------ ________________ ______` ------------ Liquid- Depth - ------------------------ <br /> I � . <br /> Capacity -------------------- Type ------------------- Material------�'�--------- No. Con portments ------I--------------- <br /> _. <br /> Distance to nearest: Well -------------- =------- ----------Foundation -------------- Prop. Line -------- <br /> LEACHING LINE I ] No. of Lines ------------------I----- Length o each line---------- ---------- Total .Length ---------------_'_--___-____ <br /> 'D' Box --------- Type Filter Material ------------:-------Depth, Filter Material _ __ --------_____ <br /> Distance to nearest: Well _______________________ Foundation -- -------------------- Property Line __________: ____------__ <br /> i V <br /> a ' <br /> SEEPAGE PIT [ ] Depth ----- _____ _______ Diameter ---------------- Number ____----,� ---------- Rock4illed Yes.'[] ?No I❑ <br /> , <br /> Water Table Depth --------------- ----------- --------------- <br /> ------ ------'=-,� :k-Size -------------------------------- f I <br /> Distance to nearest: Well -___._'-_____________-------------------Foundation -----______________� Prop. Line ,.___...:. <br /> -t% rtea I ✓ i <br /> REPAIR/ADDITION(Prev. Sanitation Permit# __-_____---- !-----------------____-____---- Date -------__________________________ ) <br /> Septic Tank (Specify Requirements) __!____.._ ” '—" —`^ <br /> --------- --------------------------- <br /> -------------- <br /> Y. �. <br /> Disposal Fie'Id (Specify Requirements] _/� �ss- - - ------ - -- ���� ---------------�Vl ------------ <br /> -- ------------ ---------`-------------------------------------------------------------------------------`------- <br /> %I J. (Draw existing and required:6ddition 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 subiect to Workman's Compensation laws of California." I <br /> Signe r, -----------A---------- Owner <br /> B yle" <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ----4k-- -- - ------------- ---------------------------------- DATE ^ fid r- ------- <br /> BUILDING PERMIT ISSUED ----------------------------------------------------------------------------------------------------------DATE <br /> ------------------- <br /> - <br /> ADDITIONAL COMMENTS ---.-----. --- <br /> -----------------------------------------------------------------------• ----------------------------------------------------------•---------------- <br /> -------------------------------------------------- - - --------------------------------------------------------------------------------------•------------------- �..._ <br /> ------------------------------ - --- ---------------------------------------------------------------------------------------------------------------------- <br /> ------------------------------------------ -- D --------- <br /> L- <br /> d <br /> Date -----1--------Final Inspection by. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'6$ Rev. 5M <br />