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FOR OFFICE USE.- <br /> t APPLICATIION FOR SANITATION PERMIT �S— 7 63 <br /> r Permit No. ... <br /> }} {Complete In Triplicate) ------•-•-- <br /> •....:............. This Permit Expires I Year From Date issued Date Issued ./..�"�.._7. <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 complea a with unty O inance No. 549 and existing Rules and Regulations: <br /> o <br /> JOB ADDRESS/LOCATION .._.x?`' .? 7� <br /> .. ..�.�---• z --- -• -�~�C�'..���'�...CENSUS TRACT <br /> ... <br /> Owner's Name <br /> -.�-- -•--•----•....... ---- - --•..... ... .......................... .....Phone <br /> Address <br /> _ City .. . .... _... . ----------------------------• - <br /> Contractor's Name -- --_ `. _. .....license # ' .GI.Q.... Phone <br /> Installation will serve: Residence Q Apartment HousexCommerc#al QTra#ler Court Q <br /> { Motel Q Other--•............... <br /> Number of livingunits:_ _ .1 <br /> _____. Number of edro ms _,�_..-:2 -._.Garbage Grinder DC7 Lot Size _ <br /> �F�S~. "!C1d <br /> Water Supply: Public System; and name <br /> .K.............................................�... private El <br /> Character of soil to a depth of 3 feet: Sand Q Silt❑ Clay Q Peat Q Sandy Loom Q Clay Loom <br /> -I! <br /> Hardpan QAdobeQ FII!Materia! .........•._ <br /> If yes, ............. <br /> (Plot pian, 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 TANG{ ] <br /> Size—..................... Liquid Depth <br /> --- •---•-- .......................... <br /> Capacity A----------------- Type ------••--••-------. Material...................... No. Compartments <br /> ................... <br /> Distance.to nearest. Well <br /> -------•............................Foundation .....----------....... Prop. Line��------•--......6 <br /> LEACHING ZINE [ } No. of Lines _-_--.----•---•---- Length of each line....... <br /> sr�"-•--....... Total Length � <br /> 'D' Box .... <br /> V.... Type Fil}er,,Matgrial.:... -----.Depth .Filter Materia! /.._..��........-•--- <br /> Distance to <br /> nearest: Well .. ....... ...... Foundation _J.._................. Property Line ._..,���...............� <br /> SEEPAGE PIT <br /> f) -els <br /> [ ) Depth r>-..:3_"_._-.--__. Diameter ._ � ..--.-;-'Number -- f_ _ Rock Filled Yes No <br /> Water Table Depth .._ ....._ .. - <br /> *,- tick Siz ................ <br /> Distance tolnearest: Well <br /> oun at <br /> .l ._........ ... ....... Prop. Line . ............ ...� r <br /> REPAIR/ADDITION(Prev. Sanitation+Permit# .............___............-•-•--...--- Date .............................. <br /> 1 <br /> a ' <br /> Septic Tank (Specify Requirements) ..................•............................................................... <br /> Disposal Field (Specify Requirements} <br /> ----------- <br /> .-----•--------- -----------------------------------------:---. -----------------------..-•-----•----- <br /> -------------- -- -- --------------•-•--•-------------••-••-•--•-----•--•-- ----------------•-----------------••---•••----...------------...........I.. <br /> -----------------------------•------•---------- --------------- <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 Son 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 parson In such manner t <br /> as to become subject to Workman's Compensation laws of California." <br /> } <br /> Signe ---••--•-••---- <br /> Owner <br /> i other than owned •� <br /> ---------------------- Title ----- <br /> DEPART NT USE ONLY 4 <br /> APPLICATION ACCEPTED BY _ _ . ..t .._ i <br /> ---•----- ------- ----------• --------------------------- <br /> ---------- ...------. DATE ...1. .. - 7 ----=- d <br /> BUILDING PERMIT ISSUED ------------------------ ..----------...DATE ..............-•--- - <br /> ADDITIONAL COMMENTS ...-_"__ _ -. . <br /> - ............... •-- <br /> -----------------------------------•------ •- :__ <br /> ..................................1-1..........I........- �• <br /> Final Inspection by. -•-•--..._.._.. <br /> p ---------••------- -- ---•-----•------- ..............................I..............---- Date .. .... ... .. <br /> � J•3 2h 1-6f3 Nov, 5M SAN JOAQUIN DISTRICT ...----S/7)I•• -3M---•-----•----- <br /> .L CAL HEALTH <br />