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FOR OFFICE USE: <br /> APPLICATION FOR 5ANITATION PERMIT ' <br />......................................................... Permit No. ;7...........-......... <br /> (Complete in Triplicate) <br />....................................•----------...._..... + This Permit Expires 1 Year From Date Issued <br /> Date Issued .. r....�...... <br /> E <br /> Application is hereby made to the San Joaquin Local Health`District fora 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 ADDRESSAO TION ;�...- .._ :.. . .. . ...........CENSUS TRACT ... ............ <br /> Owner's Name ...A ......:... • • ----=------Phone ...:::•.. -?.........._ V <br /> Address , .-.-. ,,r. ........ <br /> .. ............::........... City ---......--------------.... ................ <br /> f1P k <br /> .... ..... .-.. <br /> Contractor's Name Gt _ + 1�.-- ............ <br /> ...:......:....:...License # -- QJ- .-_ Phone . <br /> Installation-will serve Residence ❑Apartment House Vommercial ❑Trailer Court ❑ <br /> �_Motel Q Other..r.............:.:...:..:..........::........ �l <br /> Number of living units:..._...... Number of bedrooms _...........Garbage Grinder ..-.....---. Lot Size ....�.���.1��-.... ............ <br /> Water Supply: Public System bnd name . ------=................ ----------- ----------------- .......... ...Private [ <br /> Character of soil to a depth of 3 feet: Sand ❑ ..Silf[]- Clay eat❑ Sandy Loam [] Clay Loom ❑ <br /> Hardpan ❑ Adobe '❑ Fill Material ............ If yes,type ............................ <br /> (Plot plan,1showin6 size of lot, location of system in relation to wells, buildings, etc. must. be placed on reverse side:) <br /> r - . t <br /> NEW INSTALLATION:'� (No septic tank.dr seepage pit permitted if public sewer is available within 20Q feet,) <br /> PACKAGE TREATMENT [-� SEPTIC TANK t, ] Size..........._.................................... Liquid Depth ......._....._.. ...... <br /> Capacity ---'................. ----------- -----• Material...................... No. Compartments ................. <br /> L . . . � _ <br /> .Distance,to nearest: Well,,....................................Foundation ....................... Prop. Line ...................... <br /> ] --: Length of each line--------------------------- Total length .............. <br /> LEACHING LINE ` No. of Lines --:�--------- ---- <br /> µ_ ' ...De Depth Filter Material <br /> D' Box .....-...-.. Type Filter.Material �........:...:...• P ............................................ <br /> Distance to nearest: Well .:._:_.................. Foundation ----------------------- <br /> Property Line ------------------------ J <br /> SEEPAGE PIT [ ) Depth ....... .......... Diameter ...... Number ..--'...................... Rock Filled Yes [3 . No ❑ <br /> Water Table Depth ` ':;::.Rock Size <br /> Distance to nearest: Well -F Foundation <br /> Prop. Line <br /> REPAIR/ADDITION(Prev. Sanitation Permit�# ) <br /> ..........---------------------•----------.. Date ..._..................._..---•-•- <br /> 4 i <br /> Septic Tank (Specify Requirements) ................;;4**................... .............................................-- .....j.. ? <br /> Disposal Field (Specify Requirements) .-_----- r <br /> . <br /> -----------------------------------------------------------------------------------------------------------------•-----.......---•-• ..---------•-•-------_.. .-_..-..........._.......-. <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 Son 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 person in such manner <br /> as to become sub'ect to Workman's Compensation laws of Cdlifornia." " <br /> Signed ---------- ----• Owner <br /> -•----=-----=---•- . F <br /> Title . .. .. .. <br /> (If other than owner) i <br /> FO DEPARTMENT USE ONLY j <br /> APPLICATION ACCEPTED 6Y .... - ------------ -------•--------...-----......--------------------.._. DATE ... I .............. <br /> BUILDING PERMIT ISSUED .......................:... .. . ..................::...:.............................................DATE ...-................_---•-••----_--•---- <br /> ADDITIONALCOMMENTS ........................... ••-----••••-•................._...-"=----•--•----.-:....---.......•-•--...----._.....----••-•---•-•........_.._...._.....-_..... <br /> a . <br /> ......................................................... . . ............. .......Date .. -.------- <br /> SAN JOAQUIN LOCAL`, HEALTH DISTRICT <br /> k E. H-1.3 24 t-'69 Rev. 5M 7/72 3 111— <br />