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FOR OFFICE USE: <br /> ..................... I......... _. <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete tan Triplicate) Permit No. ..?.....:35. <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 existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION .... ._ .lda.......L�/llCilrlt�J................................................CENSUS TRACT .......................... <br /> Owner's Name ........ --------/0....................................................................Phone .................................... <br /> r <br /> Address . . . -two . . r.__. fGt./_._4/......................•----. City .._. .........._ ...... <br /> Contractor's Name -�-� -- - -- ---...License Phone <br /> Installation will serve: Residence artment House❑ Commercial❑Trailer Court 0 <br /> Motel ❑Other ....................... ................. <br /> Number of living units:......._._ Number of bedrooms _ Garbage GrindeLot . .............. <br /> Water Supply: Public System and name -----------------------------------r..--••---•--........� - --•--.............................Privat!1V <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Gay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe Fill Maaterial '.... If yes,type............... ............ <br /> (Plot plan, showing size of lot, location of system in relation to wefts, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION. (No septic tonk or seepage pit permitted If public sewer is available within 200 feet,) ! <br /> PACKAGE TREATMENT [ } SEPTIC TANK . ` .!.,l' �..`. <br /> ............. Liquid Depth .. 1 <br /> Capacity Type � Material.• .. .. a. { <br /> Compartments ..�.............. <br /> Distance to nearest: Well ......................Foundation ...../!� ......... Prop. Line s �.............. <br /> LEACHINGLINE [Jk--'­No. of Lines -------•---_.-. Length of each line. Total Length ..f.a?r�'.f.......:.... <br /> D' Bax Type Filter Material !^QG --------Depth Filter Material .. .................................. <br /> Distance to nearest: Well --------- Foundation ... Property Line —1;-..2............. <br /> SEEPAGE PIT ` <br /> [q--- Depth p ----�-'.-.---_-- DiameterNumber ------ ................. Rock Filled Yes (a" No iQ <br /> Water Table Depth ...------� � <br /> ---- --- ........................Rock Size ... ..,/..z _.�..�----- <br /> Distance to nearest: Well ........ke__6.......................Foundation ...... Prop. Line ........... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ......------_----...__•--------- ------ Date ............. <br /> SepticTank (Specify Requirements) ---•---------------------------•------------- ........................--......................................................... <br /> Disposal Field (Specify Requirements) -------__ ---_----.............................................--------- <br /> ----------------------------------------------------- f <br /> •----------------------------------------•----­­­------------------------------------.... ------------------------- ....... ------ - <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that 1 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. Horne 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, 1 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 �f---- `------- •-------.-_ Title -----...)�. . <br /> (if other than owner) <br /> OR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY --- -- .... ... ......................... ---------.. DATE ........ .b 7 ............ <br /> BUILDING PERMIT ISSUED -------- ------ ---------- -------DATE ....... ....... <br /> ADDITIONAL COMMENTS .................. ................. ---------------_------------- <br /> ---------------------------------------- <br /> - --- - ----- <br /> Final Inspection by ............------------- <br /> EH .. ©ate .... �.. <br /> 13 2h 1'6 Z v• 5mSAN JOA iN LOCAL HEALTH DISTRICT 8/7h 3M <br />