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Fort OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> `- ............................... Permit No, <br /> (Complete in Triplicate) <br /> ._ .................... <br /> . This Permit Expires 1 Year From bate issued Date Issued �?.............. <br /> Application is hereby made to the Son 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. 544 and existing Rules and Regulations.- <br /> JOB <br /> egulations:JOB ADDRESS/LOCATION _ ...............CENSUS TRACT <br /> Owner's Name ........ ...... ......................................................... .................Phone ..... <br /> Address ......_. City � N <br /> .............................•Q•--..'..... ..._.__.....__._. ... <br /> Contractor's Name ......a1.-i._-._ __aP,ks,{�_- �-- ------License # ... Phone V-46.-& Z.... <br /> Installation will serve: Residence [Apartment House Commercial ❑Traller Court a <br /> Motel ❑Other ............................................ <br /> Number of living units:.)......... Number of bedrooms 3.......Garbage Grinder ............ lot Size .............. <br /> Water Supply: Public System and name ---••.........................••-----------._-.-.-..---._........._-•----------------• ......................Private 0 <br /> Character of soil to a depth of 3 feet: Sand❑ .Silt❑ Clay ❑ Peat❑ Sandy Loam t7 Clay Loam ❑ <br /> Hardpan ❑ Adobe Fill Material ............ If yes,type ---------------------------- <br /> (Plot plan, showing size of lot, location ofsystem 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 [ J SEPTIC TANK[ j Size................................................ Liquid Depth .......................... <br /> Capacity ............. ...... Type ... ................ Material...................... No. Compartments .................. <br /> Distance to nearest: Well ....................................Foundation ...................... Prop. Line ...................... <br /> LEACHING LINE [ ] No. of Lines -.---•.................. Length of each line............................. Total Length ............................ O <br /> 'D' Box ..--------.- Type Filter Material ....................Depth Filter Material ..........-.•............•.................. � <br /> Distance to nearest: Well ........................ Foundation ........................ Property Line ........................ <br /> SEEPAGE PIT [ ) Depth .................... Diameter ................ Number ............................ Rock Filled Yes ❑ No >D <br /> Water Table Depth ..............................................Rock Size <br /> Distance to nearest: Well -•......................................Foundation .................... Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ............................................ Date ...._.....-- .................. <br /> Septic Tank (Specify Requirements) ...................�/�.------------•--•-••--.. -- ------•- ...._.... •-•---------•------....__..--........._..-.............. <br /> Disposal Field (Specify Requirements) 7 ?- .__ r.!��. .................. ..................... <br /> --------------- a d .Z. ...1 ...... ................. <br /> /�• r <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 perFormptyce of the work for which this permit is issued, 1 shall not employ any person in such manner <br /> as to become ect to W an's Compensation laws of California." <br /> Signed ....... . _. .- .. -- .. . ..................... ............................. Owneq. <br /> .. .. <br /> By .............. .. ...... <br /> ... ... --------._....._..........._..... Title ._--_-_..._.--._.._....-......._...•--.._...__.......: <br /> (If other than owner) <br /> O DEPARTMENT USE ONLY <br /> I <br /> APPLICATION ACCEPTED BY --6— . - ---•----••................•----...---......--........ DATE ..6. .. •„l .�/........ <br /> BUILDING PERMIT ISSUED ................................. ...... ...........DATE <br /> ADDITIONAL COMMENTS <br /> yro1Is......,, _s'.�.......y.y. '.Alar.�.R�/I'eu.............................. j <br /> •--- <br /> ..............................................•----------------------------..._.-._..--------•----•---------------•-•----........_._.....-----•-----...I-—........... <br /> ----------------------------------- ------•....................................... <br /> ----. •-••-•........----- ...... <br /> Final Inspection by: ,.. ...............--•-•.........:..................••--.................---.........._..Date ... '� .....t / ----- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> CP <br /> f <br /> �. E. H.13 24 1-'68 Rev. 5M 7/7 2-3-M` _y <br />