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FOR OFFICE USE: „ <br /> APPLICATION FOR SANITATION PERMIT <br /> Permit No. <br /> ................................. .... <br /> (Complete in Triplicate) . -.�'��,.... <br /> ............... This Permit Expires 1 Year from Date Issued Date issued ./ -I?_ :3. <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 County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION ­­­:3. ..-�Q. . .. ... <br /> !� ....CENSUS TRACT <br /> { �� .Ann- r................ .......... <br /> Owner's Name ................. <br /> ............. .....Phone <br /> . ...Address ..............f � <br /> �Ity <br /> J _....-•..................6_.......... <br /> .. <br /> Contractor's Name .License <br /> .. Phone <br /> Installation will serve: Residence 14 Apartment House 0 Commercial,'❑Trailer Court 0 <br /> Motel ❑Other ............. _ <br /> Number of living units:...----f.._ Number of bedrooms _-5....Garbage Grinder .. . __._ Lot Size ...��0_ <br /> Water Supply: Public System and name .................... —cr..•---•- .............--•_._._.Private ❑ <br /> ....__..... --....... <br /> Character of soil to a depth of 3 feet: Sand❑ 'Silt-El- Clay [] Peat❑ Sandy Loam 0 Clay Loam ❑ <br /> Hardpan ❑ Adobe Fill Material ......... If yes, type .....____............ ...... <br /> 1pfi <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 pe ' ed if public sewer is available within 200 feet,) W <br /> PACKAGE TREATMENT [ ] SEPTIC TANK "�V.-t . <br /> _.�1..�x.._C� r ............... Liquid Depth .. . Ilk <br /> i <br /> ! --....... -------- <br /> Capacity) -- -... Typ Materit�I. -_:.. No. Compartments ...Z .......... { <br /> Distance to n brest:. Well .. •....Foundation ...lQ.-�...__...._ Prop. Line ...��tLEACHING LINE No, of Lines achn line..__._�•s-_`__._. . Total Length ...�7Q <br /> 'D' Box ........ ._ 'yp Filter Material-- - --._... . <br /> -•--Depth Filter Material ,�,�..,��....----•--•-.:...:..: <br /> Dista a to or st• ell ........................ Foundation ......e'" -�------ Property Line ...... ........ <br /> SEEPAGE PITYDepth --- -- --------- Diameter ...�..,1?1,..• Number .......�............. Rock Filled Yes " No <br /> Water a Depth ..Rock Size . .._ .... �.2-ii <br /> Distance o nearest: Well -------------•...........................Foundation ../..�••� ---. Prop. Line _571 ......... <br /> �f <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ................ Dote t <br /> Septic Tank (Specify Requirements) - = = _ 1 <br /> = - <br /> ...................................................................... ----:..................... <br /> Disposal Field (Specify Requirements) ...........................-........................................................................... <br /> ' <br /> ---------------------------------------------------------------------------------------------------------- v......--------- <br /> .................................... <br /> (Draw existing and required addition on reverse sldej <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin II <br /> County Ordinances, State laws, and Rules and Regulations of the San Joaquin local Health District. Monte 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 /> • <br /> Byy/G .�. ................... ................ Title ---...----. ` 1...._........._. .__....._....__...._..........: <br /> (If other n owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY .:�� ..���• _-- DATE ....... .� '? -. <br /> BUILDING PERMIT ISSUED .. ..........DATE _.:................ <br /> --------- --------- . <br /> 1TIONAL COMMENTS_.... .......................•. --•..._......._----- <br /> --------------------- ............................................................. � <br /> ..........................................................._........------•-.....-----•-••----• <br /> Final Inspection by; <br /> .....................................................•................................................................Date ..........--=.................................... <br /> SAN JOAQUIN LOCAL"}HEALTH DISTRICT <br /> c u <br /> 1.3 24 , <br />