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FOR OFFICE USE: <br /> ............... <br /> APPLICATION FOR SANITATION PERMIT ' <br /> (Complete in Triplicate) Permit No. <br /> ...................................................... <br /> Date Issued <br />...................................•--:--- This permit Expires 1 Year From Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for apermit to construct and install the work herein <br /> described, his a plication is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> �� i <br /> .JOB ADDRE /L CATION .. ��... ��'�...:. .-_,��:. �.��...5 .... :..CENSUS TRACT .........:.... <br /> Owner's Name ..... - �. .: Phone f..:`.�S/'�........ <br /> Address ...... . /.�`L,. ...._ . ....... ...... .... .` ........:.. ,City ,....::.....::..........:......_......._:.... <br /> Contractor's Name ._ <br /> -�!. '�-r.............................. .........................License# -- - -. Phone, w, <br /> Installation will serve: Residence KApartment House 0'Commercial❑Trailer Court 0 <br /> ►Motel_❑Other <br /> Number of living units:..../..-'.'Number of bedrooms 5:-,_ .`._.Garbage Grinder .............Lot.Size . n....Xr ._ .. ..............� <br /> Water Supply: Public System and 'name, ....... -•---- y_-•••-••........... ..................................... Private <br /> Character of soil-to a depth of 3 feet: Sand'❑ Silt❑ iClay ❑ ' Peat❑ Sandy Loam fl.z-.Clay-Loam���_� " <br /> Hardpan° Adobe ❑ Fill Material ........-_ if yes,type ............................. <br /> (Plot plan, showing size of lot, location.af..system in relation to wells, buildings, etc, must be placed.on reverse side.) <br /> NEW INSTALLATION: ' (No septic tank or seepage pit permitted If ublic sewer is available within 200 feet,) <br /> �' _ Liquid Depth � . .......... <br /> PACKAGE TREATMENT [ ] SEPTIC TANWI Size_______________ _ •---..-... ---- q p <br /> Capacity .1 !�2._..__ TyperC'.....-�.-... Material--_ �``. Na. Compartments ..._. ........ <br /> f .. <br /> Distance to nearest: Well ...._�........................Foundation ....Ar............ Prop. line <br /> LEACHING LINE [ ] No. of Lines �. g w <br /> Length of eachr�e.,-J.._ c0----------.. Total length - - .............. <br /> ` 'D' Box A'.... Type Filter Material &&.__.„Depth Filter Material --------���................._.. ------ <br /> 11 <br /> Distance to nearest: Well ............ Foundation .....fL2. .......... Property Line _- ...:..::.:.... <br /> SEEPAGE PIT i(/ Depth .--_x.57__..:.. Diameter Number ........ .;----.-.-..y Rock Filled' YesNo,C3 <br /> Water Table Depth ......... ..............................Rock Size _2_0:---=----------- f <br /> E <br /> Distonce•to nearesi /Nell "'f .:........................Foundation _,/O..,.......... Prop. Line ..�..:_...._.:__ <br /> REPAIR/ADDITION(Prev. Sanitation Permit!# _..................................... .. Date .................................. <br /> --« x �1 <br /> w <br /> Septic Tank (Specify Requirements)s-.................. ..................... ......................................................_...-.:....-.......-.:.­------•-- <br /> f <br /> DisposalField (Specify Requirements) .............. ..................................-------------------------------------------------- _................ ........ <br /> i <br /> J (Draw existing-and'requiredladdition 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 Laos,-aiid-Ruiei and-Regulatio-s of­the San.,loaquin Local Health District: Home'awner or licen- <br /> sed agents signature certifies the following: a , <br /> "I certify that ' the performance of the work for which-this persmit-is-'issued, I shall not employ any person in suck manner � <br /> as to beco e s ject to Workm ''s om Datian_laws of California. <br /> Signed fG :• Owner. <br /> BY •-_-- ................. -------•;-•••-••....................... ............... .4 <br /> = Title ... ...............................-•-•- --• ............... <br /> Ilf other than owner) <br /> y F R DEPART NT USE ONLY <br /> APPLICATION ACCEPTED BY .:._. Xe L .< - ... �f� .-.......................... ...... DATE ._ '..7 ................ <br /> BUILDING PERMIT ISSUED ........:`......-----•......--•-••........--•-• ..................................•••• •-- ” •---DATE ............._... ....... <br /> --------- ................ <br /> ADDITIONAL COMMENTS ................•----------.........------...........---.- ............. <br /> ,.._.,..:-.... .............................•---•---.........................----...••_- <br /> :.. ..... ............ <br /> Final Inspection by: - 1 Date ..................... .................. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> F H 13 24 1.'AA Rav SM 7/72314 <br />