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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ---------- ---------------=--------- ---------- (Complete in Triplicate) Permit No. --- ---------------- . <br /> k <br /> - ---------------------------------- -------------------- <br /> Date Issued -__7 po <br /> --------._------_-__----- This Permit Expires 1 Year From 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 compliance with County Ordinance No. 549 and ffexisting Rules and Regulations: <br /> ' p -1 U_e�F-I1fc L1_p CENSUS TRACT - .�6 --------- <br /> JOB ADDRESS/LOCATION --- - ---� g----- �i� I <br /> Owner's Name ------- - <br /> ,� R----0,-_�-_R=S&ff -- ---------------------------- -------------------Phone ------------------------------------ <br /> A <br /> Address - ---- -- = City __4 -`------------ --------------------------------- <br /> Contractor's Name -__ - -----.License # ',�- Phone .- _ _- �r <br /> Installation will serve: Reside e�artment House-E] Commercial ❑Trailer Court ;❑ <br /> I <br /> Motel ❑Other -------------------------------------------- <br /> Number of living units:----I----- Number of bedrooms ______Garbage Grinder ---�---- Lot Size ------------•- - <br /> Water Supply: Public System and name --------------------------------------------------------------------------------------------------------------Private,®- <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt 0 Clay ❑ Peat❑ Sandy Loam -ET--�Clay Loam ❑ - J <br /> Hardpan ❑ 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 /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ I SEPTIC TANK�[ ] Size-------------------------------------------------- Liquid Depth --------------------------- <br /> I <br /> Capacity--------------- <br /> --------------- ,----- <br /> Capacity,-------------- Type ------------------ Material---------------------- No. Compartments ----------------------- <br /> Distance <br /> ----- -------Distance to nearest: Well ------------------------------------Foundation --------------.------- Prop. Line ------------- -------- <br /> LEACHING LINE [ ] No. of Lines ------------------------ Length of each line---------------------------- Total Length _-_-_-----.--_---_---_-.-.-- <br /> 'D' Box :----------- Type Filter Material --------------------Depth Filter.Material --------------------------------------•----- <br /> I Distance to nearest: Well ------------------------ Foundation ------------------------- Property Line -------.----_-_-__.--.__ <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number ---- ----------------------- Rock Filled Yes ❑ No lo <br /> WaterTable Depth ------------------------------------------------Rock Size --------------------------------- <br /> Distance <br /> ------------------------ -----Distance to nearest: Well ----------------------------------------Foundation -----------:-------- Prop. Line ..................---- <br /> REPAIR/ADDITION(Prev. Sanitation Permit#j----------------------------------------- -- Date --------`-----_----_----------,---� <br /> Septic Tank (Specify Requirements) ----- `F�- c - © � <br /> Disposal Field (Specify Requirements) -J.-C-0---- -- - - ----- --------------------- <br /> ----------------------------------------- <br /> ------------------------------------------------------------------ <br /> N ri (Draw existing and required addition on reverse side) <br /> I hereby certify that I have prepared this application andthat the work will be done in accordance with Saro 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 /> I as to become subject to Workman's Compensation laws of California." <br /> Signed ------------------------------------------------------------------------- Owner <br /> i ' Title ---------------------- ----------------------- ------------------------ <br /> BY ----- -- = <br /> [If ofiher th n owner] <br /> i <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY - -------------------•------ ----- ---------------------------- DATE __?_.a'.-----� ----------------- <br /> BUILDING PERMIT ISSUED -------------------- ---- ------DATE -------------------------- ---------------- <br /> ADDITIONALCOMMENTS ---------- ------------------------------------------------------------------------------------------- ------------------------------------------------------ <br /> ' ----------------------------------------------- -- -----`---- <br /> ---------------------------------------------------- <br /> --------------- ----------------------------------------------------------------------------------------------------------- ---------- ---- ------------------------------- <br /> ------------------------------- - ---- ----' ------ -- ------- <br /> Final Inspection by: ---- --------------------- - --- - ------------- ------------------------ Date --T.-.-- "1 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ,, , <br /> E. H. 9 1-'6B Rev, 5M <br />