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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> C. <br /> ........ .................................. J Permit No. . - _7........... <br /> (Complete in Triplicate) <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 compliance4Houseo� <br /> rdinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION 41.�7- -._�--- ... . ..........................CENSUS TRACT .................... <br /> Owner's Name ... - - -- ...-.-Phone Pho e <br /> Address ...............` �- ..-. ..... ....-• • City . ... ..A. <br /> Contractor's Name ... ... .-:._-_.Licenseone ...Installation will serve: Residence ApaCommercial QTrailer Court <br /> II Motel ❑Other ..------•---•-•............................. <br /> Number of living units:-----l..... Number of bedrooms .._5.....Garbage Grinder .......----- Lot Size .......................................... <br /> Water Supply: Public System and name ................. ... .................................:�.--..................................................... ­1_1 <br /> Private [ <br /> Character of soil to a depth of 3 feet: Sand❑ .Silt❑ Clay F] Peat[D Sandy Loam lay Loam ❑ <br /> Hardpan ❑ AdobeC3 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.1 <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK J ] Size—_..7--------------------7----------- Liquid Depth ..........................6 <br /> Capacity -------------------- Type ................... Material.;------------------- No. Compartments ....................... <br /> Distance .to nearest: Well -•-•---•----------------------------Foundation .._................... Prop. Line ............-__..-.._. Q <br /> LEACHING LINE [ ] No. of Lines . Length of each line---'......... ............... Total Length .-...........:...:.......... .n.[ . <br /> 'D' Box ...........- Type Filter Material ---------=----------Depth Filter Material .....-.............._........._.... ........ . <br /> Distance to nearest: Well -------------_-.----_ Foundation ........................ Property Line ................ <br /> SEEPAGE PIT E 1 Depth ..................... Diameter Number ............................ Rock Filled Yes ❑ No ❑ <br /> Water Table Depth ------------------------------------------------Rock Size ............................. <br /> -� .._. C s <br /> Distance to nearest: Well ........................................Foundation .................... Prop. Line ------.----.._...._. to <br /> REPAIR/ADDITION(Prev. Sanitation Permit -------------------------------------------- Date .....) <br /> SepticTank (Specify Requirements) --- --...----------------------•--------...---------------------•------....----•-•----..-..--........ ................._-- ....... <br /> Disposal Field (Specify Requirements) .--- �� _. rt!__-. 4 -------------- <br /> ----------- <br /> . ...................... <br /> . ..� - -t..- .. 1 Z X� X ° <br /> .--- ........ -------------- ---••------.....................--...--•-•--•------------------.....--_.......... <br /> (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,dicer= <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 subject to Workm Compensation laws of-California." <br /> Signed ...... _------_--------_- :. -... ........._.._,Owner <br /> By _..-.. :,. . Title ... . . .- ..-..... <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY tt <br /> APPLICATION ACCEPTED BY ... ----../ .....---••-•-•-..... -- Z.----.. DATE . S7.72Tff---------------- <br /> BUILDING PERMIT ISSUED ............. --•---........................DATE ...--•-- ------------. ................... <br /> ADDITIONALCOMMENTS .........................................................--.......................................................................:........................... <br />. <br /> ..........................................................:........................................................................••........-...............................y------------------••------- <br /> .................................. . <br /> . --• .........et`...................-...........................:...........---• ------. ............... <br /> Final Inspection by: ......... ` <br /> Date . ... ----- <br /> ._ . '' - r.?:! <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H.13 241-'G8 Rev. 5M 7/72 3 ,K <br />