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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> .......... . ...................... Permit No. ..73.-16.2.-..1.. <br /> (Complete in Triplicate) <br /> ............... <br /> ........... <br /> .................. This Permit Expires I Year From Date Issued Date Issued ./f:.. .::y .. <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 Coun y Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LO TI ........................ .... -~"..........CENSUS TRACT ........ <br /> Owner's Name ._.... ... .... _. ..... :......:..... ... ----- :.._............. .... <br /> Address . .�.��_._ . . . . .. .. '.� �... city.... -•--•--- ............. <br /> Contractor's Name ._.. �. ............ ..... <br /> rtment Housef] Commercial ❑Traller Court ❑' ° <br /> Motel ❑Other ......`.._.�. •---------------------:..... ' <br /> Number of living units:.------- Number of,bedrooms ___ (......Garbage Grinder ............ Lot Size ............ -----_ ........... <br /> Water Supply: Public System and name ------- --------•---......... ........................... ......................... ;. •-•-••...._..Private ` �4 <br /> Character of soil to a depth of 3 feet: Sand r] Silt F] Clay C] Pelt Sandy Loam Clay Loam 0 <br /> Hardpan ❑ Adobe.[3 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 TANK ] r Size___________________________ .. Liquid Depth ................ ........ <br /> �. <br /> Capacity .................... Type -•-•=--- .......... Material........ -------,__ No. Compartments ................. <br /> Distance to nearest: Well .......................•-...........Foundation ................ Prop. Line...__-...---.......... <br /> LEACHING LINE ( ] No. of, Lines -_---------------------- Length of each line.-_.............................. Total Length _.__-: .............. <br /> ::De <br /> D' Box Type F11ter�Material p ....... . . <br /> ----- -:'-_._.- th Filter Material ------".'-:-:_--:- <br /> Distance to nearest: Well <br /> ................. Foundation ......... Property .............. <br /> N t <br /> SEEPAGE PIT ( } ' Depth .................—.Diameter-..-.......... umber ._.._.:...__..___._..:_...:. Rock Filled •* Yes C], No <br /> Water Table Depth ......................Rock Size <br /> Distance to nearest:-Well .Foundation <br /> •-•-=--•---•........................... -----:._....:....... ,Prop. tine ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit ........................................... Date -----___ ......................... <br /> Septic Tank (Specify Requirements) ................. r ---=-------••-•--------;--------..Y ................................... --••-----•------- -------- <br /> Disposof Field (Specify Requirements) ......................= . ----- ----- •............. ------ <br /> . ...... <br /> ------------------------ ..... /��-, - ------ ------------------ ........................................................... ... <br /> --------------- � :. ... _.... �J�r'> --_.-_: __.l.0 ......t(`.. `-_------ - ---:`......:-- <br /> .(Draw existing and required ad ition 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 Son Joaquin Local Health District. Home owner or licew <br /> sed agents signature certifies the following: ` <br /> "1 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 subject to Workman's Compensation laws of California." <br /> g d . _ r_ <br /> ,_ <br /> Si ne --------------------�------�-•----- --•-- -------------------- --�' -- -------=-Owner <br /> BY ... r. .... ........ ... ...,Title ...... -2( _ :,_......._____...._-....... <br /> .... .... ••. -- <br /> (If other than ownery " <br /> FOR DEPARTMENT USE ONLY, <br /> APPLICATION ACCEPTED BY .._ ....................... <br /> .-.....°., DATE _.�.�.`2f." J <br /> BUILDING PERMIT ISSUED ...DATE ..................... <br /> -----------•---•........................... <br /> ADDITIONAL COMMENTS _ ------......:. � -------••-••••••••- <br /> F --•••-•.................................................. . .........••-..--•'--•--:..... .......-•----•==••--==-- ....---.......-••--- ----_... , .-. � ••-• ................1.................... <br /> ..�......�_--___ -.-- .- <br /> ..._ ..........__ ............. .. _ :. <br /> •F• �, :• <br /> Final Inspection by: ........ ....._Date (�_ `r��___.....3............. <br /> .... .. <br /> SAN JOAQUIN LOCAL HEALTH, DISTRICT <br /> i <br /> 7/11 4 u <br />