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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> z� <br /> Permit No. .. ... . .... <br /> (Complete in Triplicate) <br />- ...........__...._....._...._............... . Date Issued <br /> This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein F <br /> described. This application is made in compliance wijh County Ordinance No. 549 and existing Rules and Regulations: <br /> .... <br /> JOB ADDRESS/LOCATI /.. �1......... ..._..- ;........ '_.. =CENSUS TRACT ... ......• <br /> '' --:._... .."'w:..._.. ...... .Phone.:-....... <br /> .-. .... <br /> Owner's Name .__ :. • :- <br /> , , ...................................................... <br /> Address - ....... City <br /> :.- <br /> f . , .. / i <br /> Contractor's Name .._ - '_..... ... ... . License # ...X � ..... Phone .. <br /> Installation will serve: Residence M Apartment House❑ Commercial ❑Trailer Court 0 <br /> MotelOther ------------=----••-•------------------ <br /> Number of living units:... j.... Number of be •-- <br /> ... <br /> bedrooms .-_.,5-.,Garbage Grinder ......... Lot Size .__o�'r� .--••---- I <br /> Water Supply: Public System and name _:—............;................. Private <br /> Character of soil to a depth of 3 feet: Sand Silt❑ Clay ❑ 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, <br /> buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or see ge pit permitted if ublic sewer is available within 200 feet,[ 7 <br /> 'r <br /> SEPTIC TANK'[; e� -Liquid De th .... ...........•- --•-r <br /> PACKAGE TREATMENT��[ ] [ Sia . .. -�---�-�='.��-....-===�:.-. q p <br /> Capacity y v�JType0.� � " Material:.! '' -----Nor--Compartments .. ........... <br /> P Y / �- f K tp l Pro Line .. .................. <br /> Distance to nearest: Well ._c._.5.: -••--•-----•-•--- ---Foundation_:.� p• _ <br /> ....._. ._... Length of each line. 9 � �. ---•• <br /> LEACHING LINE [c%�No. of Llnes Total Length <br /> -..--.Depth Filter Material - --� <br /> u 'D' Box r...._._ Type Filter Materia! --- <br /> Property <br /> p A.._ _ <br /> fp rty .K.............•••... <br /> Distance to nearest: Well _...:. d_.....,__ Foundation ----..f.p___......... Pro a Line <br /> _..........:. . . Diameter ...... r <br /> Water,Table Depth -. ..........Rock Size --------_----•---_---- -Fille <br /> •.•- . <br /> Distance to nearest: Well ......................................... <br /> Foundation ..........:......... Prop. Line ---.-----------------_0 <br /> REPAIR/ADDITION Prev:Sanitation'Permit# ........................ <br /> ©ate -••-___-••.................••---••} <br /> f Septic Tank (Specify Requirements) ...................__.. ..-----­­---...._....------._...--------....-------......--•-••--•----......_--.--- <br /> --- --- <br /> T ;_ <br /> I Disposal Field (Specify Requirements) -------------------- ....................................................... <br />{ -----------------------------------------------------------•---------------------------------------------------------------------------------------- <br /> ...........---.....................------.................................................... <br /> (Draw existing and required addition on reverse side[ <br /> I hereby certify that t have prepared this application and that the work will be den# in accordance with San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Lotrel Health District. Nome owner or (iters- <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 /> t as to become subject to Workman's Compensation laws of California."' <br /> Signed ..............---------._---------._.......... <br /> ........ Owner <br /> _ 0 ` Title . �' .._....:... <br /> (If other than owner) <br /> I FOR DEPARTMENT USE ONLY <br /> I APPLICATION ACCEPTED BY .......... ••_.,r..............................- <br /> ••-_--.• DATE ... d.. l-- <br /> BUILDING PERMIT ISSUED .........::.....: DATE _........... <br /> ADDITIONAL COMMENTS _.............................................. <br /> ..................••-••.........----- <br /> i .. ................ •-••-----... ----- .........-----................ .... <br /> --- <br /> 1 Final Inspection by: . ..... <br /> SAN JOAQUIN LOCAL' HEALTH DISTRICT <br /> l 7/72 3-M <br /> 1.3 24 1_•,4A Qav_ sM <br />