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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION Pr:RlW1T 7S l U <br /> ....................�_._...........................------ <br /> (Complete in Triplicate) Permit No. ................. <br /> ................................................ <br /> This Permit Expires 1 Year From Date Issued Date Issued ................... <br /> fos3--lev •-rS" <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 a egu�atio <br /> JOB ADDRESS LOCATIO :.._....-•- -_ _..... _......_ . ... <br /> I:NSUS T <br /> Owner's Name ... . .._., ._.�. _s..�: 4 _ <br /> AX_ <br /> d ..-- ................... ......Phone <br /> Address !.. � �_�....................... ... .................. City :... ....... <br /> Contractor's Name .-•-_--... -. .... _�i�- �-•• A--------------License #iT .S. L.... Phone ..-..........._.. ............ <br /> Installation will serve: Residence ❑Apartment House 0 Commercial OTraller Court 0 <br /> Motel ❑ Other .. .....I/"t- __.._.__- <br /> Number of living units:.....I...... Number of bedrooms -----.....Garbage Grinder ___.__..___ Lot Size ..................... ..................... �.3 <br /> Water Supply: Public System and name .......................... -------- --. <br /> -• .--•---•---------------------------••........Private [ o <br /> Character of soil to a depth of 3 feet: Sand'Q `Silt Q Clay [f�Peat❑ Sandy Loam 0 Clay Loam <br /> Hardpan [❑ Adobe,C] Fill Material -----------. If yes, type ..........................• <br /> (Plot pian, showing size of lot, location of. systemin in relation to wells, buildings, etc. must be placed on reverse side.) rn <br /> NEW INSTALLATION: (No septic tank or seep ge pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK 1 Size./lam---X-f... .................... Liquid Depth ....V................... <br /> Capacity';�o�4?.:Q.._---- 'type :... Material..�+�_.. No. Compartments ...7p.—,......... <br /> Distance to nearest: Well ...........-r..a. .__....Foundation ...__/._ _ ..- Prop. line ... ...... <br /> LEACHING LINE No. of Lines ---------1.............. Length of each line.'--,..... Total length . <br /> 'D' Box ------------ Type-Filter Material __--.rte,'A......Depth Filter Material ... ./i.............I-—................ <br /> Distance to nearest: Well ._.__..�. .... Foundation ....1.Q.let ....... Property Line ....... <br /> SEEPAGE PIT [/'� Depth ....2.17.9_ Diameter ._.. _A_. Number ----------;Z 7----_---_-- Rock Filled Yes 2ro", No <br /> ..�� .... Water..7able Depth ..........-...... ' p <br /> 6- - ................ Size � <br /> .�.�r�..l�.. ...... : <br /> Distonce to nearest: Well ....... --------------Foundation ._.1Q. ._- Prop. Line ...r�...... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ......,......................._-----.-----. Date .......... ........................ . <br /> SepticTank (Specify Requirements) -•-------•...................................•-----------------......--••----•---.--•-----................•.............•-•-----•-•••...... <br /> Disposal Field (Specify-Requirements) ...................................................................................................................................... <br /> ............................. --------------------•----••- ....------------------------------------..-.-•------------------------- <br /> ------------------------------•-.....-._ <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 liters- <br /> sed agents signature certifies the following: <br /> "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner <br /> as to becomwsubject to Workman's Compensation laws of California." <br /> Signed ------------------------ .... ................. ---------_---- Owner , <br /> By .. _.._...._ . .. ,................... litl °i�•_.--_._.........._..._._.._....._..__....... <br /> (if other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY .................. ,. .................................................. .................... DATE ...��. ._�.. .. . <br /> BUILDING PERMIT ISSUED .......... ......... q t <br /> ADDITIONALCOMMENTS ..-. !.. ........................•.....---•----.....---.......---•--....---...--................................. <br /> --- ----------- -------------------------------------:... ----------------.--------....... ....... --------------------- <br /> ................................................ -•------- ------------:---------._---_ ---------.-------------.......---......... <br /> Final Inspection by: ............ . .. ........ Date ..-- / <br /> SAN JOAQUIN' LOCAL' HEALTH DISTRICT <br /> E. H.13 24 1-'6B Rev. 5M . .. ..d.. .� n . . �. . _... .,_.�.. .. y _ .-. - -•• -�- - ; <br /> 7/72 3 <br />