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FOR OFFICE USE- <br /> APPLICATION ICOR SANITATION PERMIT 7s.��6� <br /> ...................................................... Permit No. . .........__..._ <br /> .. <br /> (Complete In Triplicate) _ <br /> This Permit Expires 1 Year From Date Issued Date Issued ..�. 5 <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 Regulationst <br /> JOB ADDRESS/LO TION ....dales.--.. _. ...............I................. <br /> ......... <br /> ................."CENSUS TRACT .._...,......... ......... <br /> Owner's Name .. e. ........................................:........................................Phone ........ ' <br /> I <br /> Address ...__�fGn^„Q. .- City - .......................•------•---------...................... <br /> Contractor's Name _.. --------- --••-----------••.................•---•--License # --•----- :.._.... :.:._ Phone ..... ---------•----•--------• <br /> Installation will serve: Residence Apartment House C] Commercial.Trader Court 0 <br /> Motel ❑Other -------------------------------------------- <br /> Number <br /> ------------------------------- -- -- -Number of living units:---- ._.--- Number of bedrooms IS......Garbage Grinder -- --- Lot Size ._..I bA `................ <br /> Water Supply: Public System and name ....................................................... ------------------------------------ ...................Private ❑ <br /> Character of soil to a depth of 3 feet: Sand Silt.[] Clay .E] Peat❑ Sandy Loam ❑ Clay Loam o <br /> Hardpan p Adobe 0 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 I I Size......................-------------------_---. Liquid Depth --••-------------._ ------ <br /> Capacity <br /> ----------- ........ Type -------------------- Material.....--•-•----------__ No. Compartments ................ <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 /> Distance to nearest: Well _..-------•------------- Foundation .......................- Property Line --------•---•---.....--. <br /> SEEPAGE PIT ( ] Depth ----------------_- Diameter ......... Number ............................ Rock Filled Yes ❑ No 0 <br /> Water Table Depth ---............. ---------------------------_-Rock Size . .......................... 0 <br /> Distance to nearest: Well ........................................Foundation .................... Prop. Line ...................... <br /> REPAIR pDITION rev. Sanitation Permit# ------------------------------ ----------- Date <br /> ---••- --v---•....�..- <br /> ••---• ------- <br /> Septic ecify Requirements) .....---•....... ..... I <br /> -•- -------A.... <br /> Disposal Field (Specify Requiremn --- <br /> ---�. . <br /> l3 _t3�C•.`�....... <br /> ----------------------------------- ------------------------- -- ----------------•--••--------------------------•-•------------------------------------- .................................. <br /> (Draw 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 mannet <br /> as to become subject to Wo an' Compensation laws of California." <br /> Signe ------ --- ------- --- ra__. Owner <br /> BY --- ---- - Title --- ------ -- -------- <br /> (if other than owner) <br /> IL D4 1 FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY .. _._. DATE .... r° `_ ~ <br /> BUILDING PERMIT ISSUED --.- ---- <br /> - ------------•.-..---------------•----------------•- ------------------------ ---•-------------DATE - <br /> ADDITIONAL COMMENTS .. •-•-------------------------•----------...................1_­_­_'_­_­ <br /> ---­----------------------- <br /> . . -•••-_---- ------------- <br /> ------------- -----------.-.---------- <br /> - <br /> ------------- ---------nby: Date .-.1 Ins ectio <br /> EH 13 2h 1-68 5M SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M ' <br />