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FOR OFFI�rUSE- <br /> APPLICATION FOR SANITATION PERMIT _7_S <br /> .......... .............. -------—------------I.... Permit No. <br /> (Complete In Triplicate) <br /> ----------------I-------—........... <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 /> described. This application is made in compliance with County Ordinance No, 549 and existing Rules and Regulations: <br /> /` <br /> 108 ADDRESS/LOCATI.ON .........iiz ......... - ....................CENSUS TRACT ....... .......... <br /> .. ...... <br /> ... <br /> Owner" ......I.... .................Phone .................................... <br /> Owner's Name ....... ........... <br /> Addresstfta..?.Y.7 .............city ............ .......—....... ...... <br /> ----------- ........ <br /> Contractor's Name -------- ......I .........:..........license-;� JYS.3.9-17�_ phone .............................. <br /> ------------ .......... <br /> installation will serve: Residence C!f Apartment House C] Commercial OTroller Court 0 <br /> Motel C]Other......................................... <br /> Number of living units:...... Number of bedrooms ...r.Garbage Grinder ............ Lot Size ............................................ <br /> A.111-0....................................Private 0 <br /> Water Supply: Public System and name <br /> Character of soil to a depth of 3 feet: Sandr] Silto Clayo Pecito Sandy Loom 0Clay Loam 0 <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-1 <br /> NEW INSTALLATION: [No septic tank or seepage pit permitted If public sewer Is available within 200 feet,l <br /> PACKAGE TREATMENT SEPTIC TANK; I ----_-------------__...... ....... ...... Liquid Depth ...... ...................... <br /> Capacity ------------•..... Type -------------------- Material...................... No. Compartments <br /> ............... <br /> Distance. to nearest: Well ............. ....................Foundation ------------- ........ Prop. Line ...................... <br /> LEACHING LINE No. of Lines ------------------------ Length of each line:--.--'..................... Total Length ....... .......... .......... <br /> *D' BOX ------rr---- Type Filter Material ................... Depth Filter Material .........................t.:................ <br /> Distance to nearest. Well ---_------------_---- Foundation ................ ....... Prop" Line ........................ <br /> SEEPAGE PIT Depth -------------------- Diameter ----- Number ............................ Rock Filled Yes 0 N <br /> Water Table Depth -------------­-----_--.-....Rock Size ................................ <br /> Distance to nearest- Well _:-------_- ..........................Foundation .................... Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ............................................ Date ------ ........................... <br /> Septic Tank (Specify Requirements) --------------------------------------------------------•---•-F------------ <br /> -----_--- ___------- ............................ .......................... <br /> Disposal Field (Specify Requirements) --- ...... ..... -----------1 <br /> -----------1_1—-------------I.......... ----------------- ------------------- ................... <br /> -------------------- <br /> ---------- ---------------------------------- ----------7----- ----------------*----------------------........................—------------------------------------------------- ...... ......... <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 Son Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the Son Joaquin Local HealthDistdct. Home owner or Ilcen- <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 ---------------------------P - <br /> . ...... ......i__---------- Owner <br /> By .......... - <br /> --------------------- ........... Title ----_------------_------- <br /> ilf other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY . -----------------------------_--- ---------- ........... ------DATE <br /> BUILDINGPERMIT ISSUED ............ ----------- --------------------------------- .............................. --..DATE ---_------- ............. <br /> ADDITIONALCOMMENTS -------- ------------------------------------------------------------------------- ......---.........--•---- ------- --...---......:-.-•------•----.....--..... <br /> ------ -------- ------------------ -.-.-.-.------------------ ---------------------------.-.--.--------.-----.-.-­--.-.-.-.-..-.-.-..-.-.-.-.-.-.-_--_--------_------------------------------------------- -----------------------------------------.-­--�--i-------.-.-.-.-.-.-.-.-.-.-.-.-.-.-.- <br /> . .-Dterk. .. 1. ...... ......Final Inspection by: . .......-.-_-------_•------------------------------I . , <br /> ------------------------ --------- <br /> EH 13 2L 1-68 Rev. 5M SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M <br />