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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> ----------------- - ---- Permit No. ---------- <br /> (Complete in Triplicate) <br /> -------------- --------__ ----------- • Date Issued <br /> --------------------------------------- This Permit Expires I 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 /> desgribe-d. -h- ap Ii at1pn is madeiin compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> C. - � � -Vi f/i � <br /> 4-f �o d ...0-----­­-----CENSUS TRACT _---.-JOB ADDRESS/LOC ....... -------- ... ..... . V�< <br /> --------- Phone ------ <br /> Owners Name - --- ---- -- <br /> Address .------- ----------Y/. ---- ------ --- --- -- ------------------_ .......... City .......... ---------------- <br /> Phone <br /> Contractor's Name ......... -------•--•-------=..............License <br /> Installation will serve: Residence E] Apartment House[] Commercial)railef Court 0 <br /> Motel 171 Other ---_-----------_-----_--_-- <br /> Number of living units:----_--.__ Number of bedrooms _.........__Garbage Grinder..._--_--_ Lot Size __--------- ----------------------- <br /> t. <br /> Water Supply-. Public System and name ------------- ---------- ------- ----------- ------ ------------- <br /> --------.._._....-•--__-. .-Private <br /> Character of soil to a depth of 314ef,:: 'Sand El Silt EIZ /Cloy El Peat.[:] Sandy Loom -E] Clay Loam.0 <br /> Hardpan r-1 Adobe w Fill Material ---------_ If yes,type _...._-------------------- <br /> (Plot <br /> ....... ----------- ------- <br /> (Plot plan, showing size of lot, location of system in -relation to-well Uildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION- (No septic tank or seepage pit permitted if­public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT f I SEPTIC TANK;[ ] <br /> ------I-------- ....... .. -----_--------- Liquid Depth _-------------_------ <br /> Capacity ----------- Type <br /> ....... --------.. Material.........i��_---- No.-Compartments ..._-------- <br /> Distance to nearest: Well ... ...... -------------------Foundation -------------_...... Prop. Line <br /> LEACHING LINE No. of Lines _......:_........ 4-ength of each line__ ---------------- Total Length ........................... <br /> ,I), Box ---------_ 14e Filter'Material -:-:..":..-Depth Filter Material ----- -------------........................ <br /> F%, <br /> .Distance to nearest:Well-_.::_ .......... 'Foundation Property Line. -.-.___.._._-.--_---_ <br /> SEEPAGE PIT Depth -------------------- Diameter Number ....... --_--_--------- Rock Filled Yes E] No C <br /> Water Table Depth I-••_..... ------- `\. Rock Sizfe ....................... ....... <br /> Distance to nearest- Welt'.. <br /> ------ ---------Foundation -..•......._..._... Prop. Line ---------------------- <br /> REPAIVADDITION(Prev. Sanitation Permit ---------- ------------ -------------------------------- <br /> Septic Tank (Specify Requirement') .......... -------------- ------- ...............------ ------------­-- ....... <br /> Disposal Field (Specify Requirements) _A ----- - ------------- - ­­�A----------- <br /> 40-.eJ <br /> ------- ------- ----- .. ---------------------_---------------- <br /> ............................ ---------- ............... -------- <br /> ---------- ----- ---------------- -------------- -----=-----------•----.-------•--------=----•---.......... <br /> (Draw existing and tcluired addition on reverse side) <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with Son Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the Son Joaquin Local;Health District. Home owner of licen- <br /> sed agents signature certifies the following: I t <br /> "I certify that in the performance of the work for which this permit Is issued, I shall not em.illay cny person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed ------------------- ----- ........................­­ Owner <br /> By .- - -- ----- -------- --- - - --------- ----------------- Title -------------- ---4b <br /> (ifan owner) <br /> orl FOR DEPARTMENT SE"LY 4 <br /> -------------- <br /> ­ DATE .... <br /> APPLICATION ACCEPTED BY ...... - ---w�_� <br /> ----------*------------ <br /> DATE ............... ..........------------- <br /> BUI1DING PERMIT ISSUED --------- ---------------------_--- --- --- <br /> ADDITIONALCOMMENTS...0_--------­-------------------- ------- ---------------------------------------- •-----------•-•-----•---•--- --------- ------------- ------- <br /> --------------------------------- --------------------------------------- <br /> .......... <br /> ------------------------------------------------------------------------------------------------------­ ------ :.._..--..------•- <br /> - -------- - <br /> --- --------------------•--------------•------------- -------------------------------- ------ ----_------------- -- ---- <br /> h <br /> 4.-Date .------- <br /> Final Inspection by: ---------------------- ------- --_-_------------ ...... ------ <br /> SAN, JOAQUIN LO L AL,.TH,_?I�S, RICT <br /> -2s <br /> E. H. 9 1-'b8 Rev, SM. <br />