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-f <br /> FOR_ .OFFICE USE: 4-'`l,_`�PPLICATION FOR SANITATION PERMIT <br /> _ Permit No: <br /> F - - <br /> ------------------------------ ----------- (Complete in Triplicate) <br /> ------- - ---------------------------------------------- Date Issued Ar - ® <br /> This Permit Expires 1 Year From 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 made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> 40'..--CENSUS TRACT ' ---------- <br /> Z�fDt_� <br /> JOB ADDRESS/LOCATION . - - -7 <br /> ---------- `--------- - <br /> Phone$ F <br /> Owner's Name -----�A� -------------------------- <br /> Address -------- <br /> ---------------------------------------------- <br /> city <br /> Contractor's Name ' ---• ---------------------------------------------------------------- <br /> - - ---------- ------------ --------- ---------- ------- <br /> -_.License # ------- ---------------- Phone <br /> Installation will serve: Residence ❑ Apartment House❑ Commercial []Trailer heart <br /> sMotel ❑Other ----- ------------------------------------- <br /> Number of living units: Number of bedrooms ---� ----Garbage Grinder ------------ Lot Size "4- ----- <br /> Water Supply: Public System and name ------------------------ ------------------•------------- Private <br /> ---------------------------- -- - <br /> Character of soil #o a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat ❑ Sandy Loam)t Clay Loam <br /> Hardpan ❑ Adobe'❑ Fill Material ------------ If yes, type --•----------------------- cb <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 available within 200 feet,,) r <br /> SEPTIC TANK: Size- ur 1 ` Liquid Depthd/_'�_-•-------------- <br /> PACKAGE TREATMENT [ - <br /> -_- No. Com artments !7 -_...-------•---- <br /> Capacity+�- - ------- TYpe f� Materiol!t� p <br /> I Prop. Line -_`r- <br /> Distance to nearest: Well ----------------- _ld-- --_----_--- ---- <br /> f ' <br /> LEACHING LINE [Xj No. of Lines -------------------- <br /> � Length of each line-__Cd---------------- - Tota! Length J- -- -•-.------------ <br /> 'D' Box ---------- Type Filter Material --------------------Depth Filter Material ------------..-------------------- <br /> •-- <br /> i __ Foundation Property Line -------------- -------- <br /> I Distance to nearest: Well ---------------------- ---- ---------- ---- <br /> De Depth .1 Diameter ---------------- Number ---------------------------- Rock Filled Yes ❑ No <br /> SEEPAGE PIT L 1 p ,T---- ----------- <br /> WaterTable Depth --------------------- --------------------------Rock Size ------------------------- ----- <br /> "iFoundation ------•------------- Prop. Line -------• ------------- <br /> Distance,to nearest: Well ------------------------------------­- <br /> :l <br /> ------- -- ---- ------Date - ---------•----------------------) <br /> REPAIR/ADDITION(Prev. Sanitati in Permit# -------.----------------=-------- <br /> Septic Tank (Specify Requirements) ----------------------------------------------------------------------- - <br /> ------------------------------------------------- <br /> Disposal Field (Specify Requirements) -------------- -- ------------------------------------------------ <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. Nome 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, l shall not employ any person in such manner <br /> as to becom ubaect t W man' Co sation laws of California." <br /> Signed ------------------------ -------------- Owner <br /> t ----------- Title - --------------------------------------------------------------- <br /> (If other than owner) <br /> Of FOR DEPARTMENT USE ONLY <br /> DATE 77/-A- <br /> APPLICATION ACCEPTED BY --- - ---- c.�.� ------ <br /> -�a--•------------------- <br /> BUILDING PERMIT ISSUED --- ---"--------------------------------------------------------- -------------=-----DATE -- <br /> ADDITIONAL COMMENTS -------- ----------------------------------------------------------- <br /> ------------------------------------------------------------------------------------------ <br /> ---------------- <br /> ---------------------------------------------------------------------------- <br /> 1------- -- = <br /> ------- <br /> Final <br /> Inspection <br /> ------------------Date �- <br /> Final Inspection bY: --- --------- -------------------- ------------- - <br /> k SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'h8 Rev. 5M <br />