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FOR OFFICE USE: APPLICATION .FOR SANITATION PERMIT <br /> Permit No. <br /> --------- .............•--................... <br /> ...... ..7�."_.��..�� • ' <br /> (Complete in Triplicate) ' <br /> ............................... J` <br /> Date Issued ............:....... <br /> This Permit Expires ] Year From Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a per 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 ADDRESS/LOCATION .,:.C- • .` .._-. - ...__....•......--. CENSUS TRACT ::........................ <br /> Owner's Name r.. CT Lr ^- ....................................................................•---•-•--.......;...Phone .......... <br /> City <br /> Address _ ..................... ... .......... 1 <br /> ..------ �1 <br /> ....License # '-- -- Phone <br /> Contractor's Name ... •-- ....! �' ' <br /> Installation will serve: Residence Apartment ouse❑ Commercial ❑Trailer Court <br /> Motel ❑Other ............................................. <br /> E Number of living units:...- ___-- Number of bedro ms .... Garbage Gr' der ............ Lot Size ..y3i .- 1••••••-•--•- <br /> nJ ..e... --- -----•---.......Private-❑ <br /> Water Supply: Public System and name ........ ...... <br /> Character of soil to a depth of 3 feet: Sand'❑ . Silt❑ Clay ❑ Peat❑ Sandy Loam {] Clay Loam Jq- <br /> Hardpan [3 Adobe E] 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 /> I NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT ] SEPTIC TANK Size.... ..X�. .• .I�..... ........ Liquid Depth .. �.-.. ...........,..... <br /> Capacity .�.. -d Type ....... Material....�,<.- ._... No. Compartments •- •..... ........ ' <br /> T e <br /> Distance to nearest: Well ...............Foundation ..Zo............. Prop. Line ...,,tr. .............. <br /> - .M <br /> - -•- --. 1--------------- Length of each line.- �................. Total Len��g^^th ......_... <br /> LEACHING LINE ]- No. of Lis w Type Filter Material ......ff_ '...Depth Filter Material ..1-k.-..•...............•-•.......-- <br /> D' Box <br /> Distance to nearest: Well ........................ Foundation ........................ Property Line ...............----.---- <br /> SEE-P, G�,iT-- } DeptV__ I� Diameter ....._•__..•.___ Number ...-.__�....... ...... Rg Ik Filled YesT <br /> No i❑ <br /> c p .1 <br /> J � Water Table Depth ................../...•---....-................---Rock Size .............-1.•m ..------ <br /> Distance to;nearest: Well _---l _�i .:e....................Foundation ..........•...__.... Prop. Line <br /> REPAIR/ADDITION(Prev. Sanitation;Permit# ...................................-.. Date ........ <br /> Septic Tank (Specify Requirements) --------------------`----------- <br /> •----------------•-••-------•-•----------------•--....-+....-- ---------...._.-..----------.... -----------.... <br /> Disposal Field (Specify Requirements) ---_--.--___ <br /> ............................................-.................--------------................ .-------------.. ........... ---........ <br /> .....................I—...-----....-.,...... <br /> .. <br /> (Draw existing and required addition on reverse side) <br /> 1 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 person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed ..... _.. - ------------------------ Owner <br /> C <br /> (I of ee than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY DATE <br /> ..................•-- <br /> BUILDING PERMIT ISSUED ... :. .............. ---.....DATE ....... <br /> ADDITIONAL COMMENTS ..........--•-•..............................:.......................... <br /> ------ -------------------- •- :.. ..---•--.................----••---•--.................------•--•--...._•..... ........•. -- . <br /> FinalInspection by: ...... .......................................-......................................Date <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> . <br /> 13 24 , •moo n_-. cxa' 7/72 3 M <br />