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FOR OFFICE USE- <br /> APPLICATION FOR SANITATION PERMIT <br /> .....................[1-- Permit No. <br /> (Complete In Triplicate) <br /> ................................ . ;2 -'76 I. <br /> .. .............. <br /> 11 This Permit Expires I Your From Date issued Date Issued ............1...... <br /> .. <br /> Application Is hereby made 11 to the Son Joaquin Local Health District fora I p'ermIt to construct Ct and Install the work herein <br /> described. This application Is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: d <br /> ....CENSUS TRA q T ............. .......... <br /> ........... ................ ................. <br /> JOB ADDRESS/LOCATION <br /> ........... <br /> Owner's Name ........... .................. ............ .............. ..............Phone z <br /> - - ----------------- ..... ....................... <br /> --------- .............License # one <br /> Address - ----- a.2 <br /> Contractor's Name ------ h <br /> installation will serve: Residence[]Apartment House 0 Commercial 1RTraller Court <br /> Motel 1`1 Other ---------------------------------------- <br /> Number of living units .... Number of bedrooms .....'.:___:Garbage Grinder -----------I- Lot Size ----------------- -­------------------- <br /> ... <br /> Water Supply- Public System and name ................... ......... ----------­ -------- -•--------------------------------------. Private 0 <br /> 0 <br /> Character of soil to'a depth.°f 3 feet: Sand 0 Silt 0 Cloy .0 P&at.Q . Sandy Loom 0 Cloy Loom <br /> ... .. .... <br /> -HardpowC]­,-AdobeCJ fillWaterial ..............If Yes!type_.__-Z.­.... .......... <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. sep tic tank or seepage pit permitted if public sewer is available within 200 feet,} <br /> PACKAGE TREATMENT SEPTIC TANKI Size - -...... ... ........ ----- - Liquid Depth .......... ------ <br /> ........ <br /> _-------------- No. Compartments ....------------------- <br /> Capacity ------------•-- -- Type -----_---- Material <br /> Distance to nearest: Well .........:...`g .......'L.......Foundation ... Line ----- ........................... Prop. ...... <br /> Total Length ........... ................ <br /> LEACHING LINE No of Lines ......_---------------. Length of each line......... --_----------- �V�--- <br /> V Box ...........- Type Filter Material ......... ..........Depth 'Filter Material ............................................ <br /> Distance to nearest: Well ....... ................ Foundation ......-............•_.... Property Line ............. <br /> SEEPAGE PIT Depth ...................... Diameter ....... Number ............................ Rock Filled .-Yes. 0 No <br /> D <br /> ater Table Depth ......: ....... .................... ---Rock-Size ................................... --------- Prop. Line ...............stance to nearest: Well ... ...Foundation ..... <br /> REPAIR/ADDITION(Prev. Sanitotion,p�rrnit --------------- ©ate._ .....-- ...... ------------------- <br /> ------------- ---------- <br /> ............ <br /> Septic Tank (Specify Requ" irementsl .......... <br /> ----------- <br /> Disposal Field (Specify Requirements) <br /> ....................... .................... <br /> I ---------- <br /> ------ --- -- <br /> ----------­------------------ <br /> ti <br /> 4: ............... ---------- <br /> ----------------------------------------------7 -7---------­--- --- <br /> 1Draw existi n-g"--and required a-ddition'on reve <br /> I hereby certify that I ha%,p 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 11cen. <br /> sod agents signature cortlffesthe following:' <br /> "I certify that in. the performance Of the work for'which this.permit is issued, I shall not employ any personIn such manner <br /> as to'become subject to Workman's Compensation laws of California." <br /> Signed -------_---_--_----------- - ------------------------------------------ <br /> Owne <br /> 11 Title<, — - - ----- ----------------- <br /> ------ <br /> ------------------1--------------------------------------------------- <br /> (if other than',owner) <br /> FOR DEPARTMENT USE ONLY <br /> - -` - -V% <br /> APPLICATION ACCEPTED BY S�e ............. ------- DATE ...........I.................... <br /> ----------- ----------------- <br /> - - --- ------ ---- ------DATE....... ------------------ ---------- <br /> BUiLbING PERMIT ISSUED'., --- --- ... ... <br /> .r. <br /> ADDITIONAL COMM --- --- ---- -------- .. . ... <br /> "Ce <br /> COMMENTS <br /> -----------------------------------_­--------- . ...... ---- ---------- <br /> ............................................. ...... ..... ... .... ........... <br /> ............ .... .... ........ <br /> ----------------------------------- <br /> .......... ... - ----------------------------- ........... ..... <br /> finalInspection by.. ----------------------------------------------- -------------------- -------- <br /> EH 13 24 1-68 Rev. 5M SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3H <br />