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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT r�/�41 <br /> -------- ------- ------ ----- Permit No. <br /> - + <br /> (Complete in Triplicate) <br /> ------------- ---------------I--------- ------ r <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 /> i <br /> described. This application is made in compliance with County Ordinance No. 549 and existing Rules qnd Regulations: <br /> IApo�� `i`� RCENSUS TRACT <br /> I WA <br /> JOB ADDRESS/LOCATIOI r- --------------------------- - - /--� - - <br /> Owner's Name . ' �-�. --'-----------"------ , v --------------Phone ------------------------------------ ] <br /> Address -._._ ,-- l3-�a�-- / ---------------------•--- City <br /> Contractor's Name --.-J�xcGd- � "/4e--, -s-¢ --------- ----------License # 1-Xd'3 _1"'_ Phone ---------------------•----•--- <br /> Installation will serve: Residence E�Apartment Housef] Commercial :❑Trailer Court i❑ <br /> Motel ❑ Other - -2 -ORI <br /> Number of living units:__.-.- Number of bedrooms-� Garbage Grander ------------ Lot Size ------------------------__________ <br /> Water Supply: Public System and name ----------------------------------------------------------- --------------------------- - <br /> __-_______Private [ <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Po Peat❑ Sandy Loam [r Clay Loam ❑ ' <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.) <br /> NEW INSTALLATION: - (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANKcZ Size-q-Y49_1"'_�%__4 --------------------- Liquid Depth _y......... ------------ <br /> Capacity A-WVW,64ype __--W l-________ Material__I� .� No. Compartments ........:.... <br /> f .: <br /> Distance to nearest: Well -----------1 QO-_r_______________FoundationQ-1-___---__ Prop. Line ------5------_-__--_ <br /> ------ Length of each line___-._---17a--____---____ Total Length ----------------------------- <br /> -D' <br /> __ _" -- . <br /> LEACHING LINE [ No. of Lines -__._-_�_______ g - - ------ <br /> Al <br /> 'D' Box _f .----.- Type Filter Material ---A-:------Depth Filter Material ---Iy-A---------I----------------------- <br /> Distance . o nearest: Well -----A �?___-------- Foundation --------/d............ Property Line -------------------- <br /> � i <br /> [ l Depth --- -----/_4_ <br /> B crrrreter �_s A _L3- Number -------�----------------- Rock Filled Yes No CC] <br /> Water Table Depth ------------�6--- -------------------------Rock Size ------- <br /> D <br /> istance to nearest. Well ------------XJ�€'--------------------Foundation -------- Prop. Line , -_ ........... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) <br /> SepticTank (Specify Requirements) ---------------------------------------------------------------- ------------------------------------------ -------- -------------------- <br /> Disposal Field {Specify Requirements) _____________ ------------------------------------------- F <br /> - --------------------------------------------------------------------------- <br /> -----------------------------------------------------------------=------- ------------ <br /> ---------- ---------------------------------------- fi <br /> ------------------------------I-------------- ---------------- ---- -------------------------------------------------------- ------------------------------------------------------- <br />'4 (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. Home 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 parson in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed ---------------------------------------- - --- ------- Owner <br /> BY. /�-� � V 1 Titde- - <br /> ---- <br /> (If other than owner) <br /> OR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BYDDATE <br /> ATESff <br /> BUILDING PERMIT ISSUED ------------ ----------------------------- -------------------------------------------- <br /> ADDITIONALCOMMENTS ---------- -------------- ------------------------------------------------------------------------------------ ----------------------------------------------- <br /> -------- <br /> ----------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------- - ---- <br /> -------------------- - ------- <br /> Final Inspection by. ------------------------------------ ------------------------------Date - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 4 <br /> E. H. 9 1-'6B Rev. 5M <br />