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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> 1Complete In Tripllcatel Perini!No. <br /> ......... ............ <br /> This permit Expires I Year From Date Issued Date Issued ...... <br /> ..... .............. <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 matte in compliance with County Ordinance No. 544 and existing Rules and Regulations- <br /> JOB ADDRESS/LOCATI N -l- k.31.....,..,Z .. f. _ G ..........:...................................CENSUS TRACT -----•---- ........ <br /> .11 <br /> Owner's Name --•--• ........ <br /> Address -"- ..• ...........Zt-O .......City . .......�`...._..._......_... ................................. <br /> Contractor's Name - !-�'. ----- -- ........ License d` .1.� :.. Phone <br /> Installation will serve: _ Residence Q Apartment House Corn rcial OTraller Court, 0 <br /> -Motel ❑Other....... <br /> Number of living units:... ._._ Nufribbr"of-bedrooms ....7...Garbage Grinder Lot Size <br /> Water Supply: Public System and name .........................................................w............................. .. ..-- private <br /> Character of soil to a depth of 3 feet: Sand o Silt o Clay ❑ PeatE3 Sandy Loam lay Loam ❑ <br /> Hardpan ❑ Adobe❑ 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 [ ] SEPTIC TANK ] Size................................................ Liquid Depth .......................... <br /> Capacity"................. Mater€al.................... No. Compartments <br /> Distance to nearest: Well ....................................Foundation ...................... Prop. Line .................... <br /> LEACHING LINE [ ] No. of Lines ........................ Length of eachfine-........................... Total Length -----_.____.----.... ....... <br /> 'D' Box ............ Type Filter Material ..............:.....Depth Filter Material ............................................**0 <br /> Distance to nearest: Well ........................ Foundation --...................... Property Line ........................� <br /> SEEPAGE PIT { ] Depth ........•-------__ - Diameter ................ Number ............................ Rock Filled Yes Q No [}� <br /> Water Table Depth --------------:.................................Rock Size ................................ S <br /> Distance to nearest: Well .......Foundation ....... Prop. Line ............ <br /> REPAIR/ADDITION lPrev. Sanitation permit ....... Date ...................... } <br /> SepticTank JSpeci.fy Requirements) ........................................•---..............----.......-•---...-•-•----------..............._.....o........---••-•---•-------. <br /> Disposal Field (Specify Requirements) 6x� ....... .._. � �%�- � . <br /> . • --�'�'� � -----------------------•---------------------------------------------------------------- <br /> y <br /> ------------------------------------ ------- -------------------- ----------------.......----------..................... ......----•-.-._...------------..._............._..........--------••--..--- <br /> Prow existing and required addition on reverse side) <br /> I 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 /> BY I '�` 'tie _. ..... . - <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ---- -' -------- --------------=----------------- ......... DATE 7 _�3--�_-..-------------•-- <br /> BUILDING PERMIT'ISSUED ---------------- --------.-.----..-_---.. ------- -------•--- <br /> ---DATE --- ----- <br /> ADDITIONALCOAWENTS ------------•--••-------- ---------------------- ........................... ------------------- --- ----------------- .-....... = <br /> ---------------------•._.._..-----------•--•- •--------------------------•------- ---------- ------.......------------- ...-------------------•------------- ------ <br /> ------------------------------------ <br /> .--•------ • <br /> Final Inspection by: -------- ----- :_ ..-_---- <br /> .Date _. i ...... ,......... .. <br /> Eli 13 2h 1-68 Rev. 5M /X1 <br /> JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M <br />