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-fOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> -------------------------------------- - �J <br /> (Complete in Triplicate) Permit No. <br /> Date Issue (15F <br /> _________________________________________________________ This Permit Expires 1 Year From Date Issued V <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and ins a l the work herein <br /> described. This application is made in compliance with County Ordinance No 549 and existing Rules andRegulaatio�nss. <br /> JOB ADDRESSAOCATION . - -3-`g ,- - d -z---- -------�!v� ----- -- r WCENSUSS TRACT -S-4)l------------- <br /> Owner's Name .l y / ----------------------------------------------- <br /> ----- ----------Phone <br /> Address _ City s --------------------------------------- <br /> Contractor's <br /> ----------------------- <br /> Contractor's Name ..-----------------A�� mrent <br /> ---------------.License # ------------------------ Phone --------------.--..---.------ <br /> Installation will serve: Residence House❑ Commercial ❑Trailer Court ❑ <br /> Motel ❑Other ------- <br /> Number of living units:.-_-I----- Number of bedroo s __�,3j___--Garbage Grinder'_t, y- Lot Size _L ----------------------------- <br /> Water Supply: Public System and name ------------- -----------------------------•------------------------------------------Private d;;r ! <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ., <br /> 'Hardpan , Adobe•❑ Fill Material ------------ If If yes, type -------------_.-._-__------ R <br /> (Plot plan, showing size of lot, location of system in relation tar 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 feet,j <br /> PACKAGE TREATMENT [ ] SEPT Size--cfbf'_--._5 ----------------- Liquid Depth-------_-- __.._— <br /> Capac' y - — ----- - ype �._ e Material_-f - r�-- --- No. Compartments --_ ''-------------- <br /> Distance to nearest. Well —0-6-------------------------Foundation ---AL2------------- Prop. Line.. _.__------- <br /> LEACHING LINE No. of Lines _-2—----------------- Length of each line----f_-------.------ Total Length ._ - ---------- <br /> 'D' Bo> IX-_!ol-ype Filter Material -X1_ ------Depth Filter Material -----11"p,.............__-------------- <br /> ' <br /> Distance to nearest: Well ---47A------------- Foundation _ -------------- Property Line _-----_-_-_-_-___-._--_- <br /> SEEPAGE PIT [�' Depth ' --------- Diameter _-- -3------ Numbe ---`�' ----------------- Rock Filled Yes,8 No i❑ <br /> Water Table Depth --R—-------------------------------------Rock Size -4�- --- ---r--------------- L <br /> Distance to nearest: Well - - ----------------------------Foundation J.0---------.---- Prop. Line .5 ---__-___._-_.. <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ---_-__-_----__--.._--.----------) <br /> SepticTank (Specify Requirements) --------------------------------------------------------------------------------------------------------------------------------- ------_- <br /> Disposal Field (Specify Requirements) -------------------------------------------------------------------------------------------------- ---------------------------------- <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. Hoene 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 bec subject to WgIr�mpen ation laws of California." <br /> Signed - ... - / t -t-dam ----------------- Owner <br /> BY -- -------------------- ------------ ------------------------------------------------- Title -- ----------------------------- <br /> ---------------------------------------- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY __ -------------- DATE ----- ----G------------------ <br /> BUILDING PERMIT ISSUED --------------------- -- +--------DATE ------------------------------------ <br /> ---------------------------------------------------------------- -- ------ <br /> ADDITIONAL COMMENTS ------- ' ' t- ---- <br /> ---------------------- /- "t% `' ' -----�� - �y ----�-}/---------- -- ---- - <br /> ---- - - - ---------- - --- <br /> ion by - = <br /> Final In ection b M.� _ _Da <br /> p Y - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'6$ Rev. 5M <br />