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FOR OFFICE USE: 00 C4 N <br /> APPLICATION FOR <br /> SANITATION PERMIT <br /> _........... ..... .................... Permit No. ..7..-3.-la�� <br /> ................................................... ... <br /> (Complete in Triplicate) <br /> .. This Permit Expires 1 Year From Date Issued Date Issued Z/"�" .�3. <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. 544 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION ?6767.00. f_.S„Z?t W4./ J7 v A. C ..........CENSUS TRACT <br /> Owner's Name ...R,fl, <br /> ..............G ea #.�............................................Phone .................................... <br /> Address ....................................................................................................... City ----............•--.. ....•--...... .._.............................. <br /> Contractor's Name .......................License Phone ............. `� <br /> Installation will serve: Residence IM Apartment House 0 Commercial ❑Trailer Court 0 <br /> Motel ❑Other ............................................ <br /> Number of living units:............ Number of bedrooms ............Garbage Grinder ............ Lot Size ... "O ....X f O o <br /> . ...................... <br /> Water Supply: Public System and name ........ C.. .....................................................................Private ❑ <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay jK Peat❑ Sandy Loam ❑ Clay 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.) JU <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) d <br /> PACKAGE TREATMENT <br /> [ ] SEPTIC TANK-[ ] Size................................................ Liquid Depth .......................... g <br /> Capacity .................... Type .................... Material...................... No. Compartments ...................... rC <br /> Distance to nearest: Well ....................................Foundation ...................... Prop. Line ...................... S <br /> LEACHING LINE [ ] No. of lines ........................ Length of each line............................ Total Length ............................ o <br /> 'D' Box ............ Type Filter Material ....................Depth Filter Material j <br /> Distance to nearest: Well _ Foundation ........................ Property Line ........................ <br /> SEEPAGE PIT [ ( Depth .--..... ........... Diameter ...........•.... Number ............................ Rock Filled Yes ❑ No C3 <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) ..........................................................................•__._....-..-.._.-..._......._.._........._........._..._.. <br /> ------------------- -•--------------....--.-----...-........-------------------------..-...----------------._.---------------------•---•----------._.-....-....-_....-•-..........-_..._.._..-••••••..... <br /> (Draw existing and required addition on reverse side) r <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin W <br /> County Ordinances, State laws, and Rules and Regulations of the San Joaquin Local Health District.Hem* owner or licm. <br /> sed agents signature certifies the following: <br /> "1 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 becom* subject to(Workman's Compensation laws of California." <br /> Signed .--. �.- .. �.or1r. .... alY. .--_.. Owner <br /> By —.............. . . . ... ............................................. Title .......-.....-..._..................-._.....-_...__......._............. <br /> If other t <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ....................... ............ DATE <br /> BUILDING PERMIT ISSUED -•..........................:DATE ........................................... <br /> ADDITIONALCOMMENTS ...........:......................................................_..........__._.......................-..-.......-..............:............._..._......... <br /> ........................•----.........................,.................._.._........................................_.........---....................................-•---..............-•-•............. <br /> _.......---•---•................................................_.........---.............---.....__......-__....---....... .................-................,......._........-..__...._............. <br /> ...............•--••----•-----...._................._...............,.._...._.........•......---,-.........._•-•-•-••....... ......................... <br /> Final Inspection b : Date lG-? .............. <br /> SAN JOAQUIN LOCAL HEALT DISTRICT <br /> E. H.13 241.'68 Rev. 5M 7/72 3 M <br />