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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> {Complete in Triplicate) . . c, <br /> Permit.No -< <br /> -... ................. _ . — .- - . � F� �:�� i <br /> This Penmit Expires ? Year from Date Issued Date Issued .................... <br /> Application is hereby made'to the San Joaquin local Health District for a permit to construct and install the work herein <br /> describehis This application Is made in compliance with County Ordinance No. 549 and existing Rules alnd Regulations: <br /> JOB ADDRE55%LOCi4Ti0 .IZ � n <br /> ' ....1� s........... ......................CENSUS TRACT <br /> Owner's Names --y� _ p _ , <br /> a.d.. ............................. Phone 9-?. Q....... <br /> .... <br /> 7.a �i:?.4. ... . _....... City <br /> Address . . . .... <br /> Contractor's Name .............. _ _ license tit . . . .... 'hone �6 f,4 <br /> _ ...... <br /> Installation will serve: Residence `Apartment Housefl Commercial ❑Trailer Court ❑ <br /> ii Motel ❑Other ....... <br /> Number of living units:"....'�.. Number of bedrooms r ` <br /> .. Garbage Grinder ............ Lot Size ...:. .. <br /> .. <br /> Water Supply: Public System'and name ........................................... .. <br /> ... .:..PrJvate <br /> Character of soil to a depth of 3 feet: Sand Silt <br /> .. _ O O_ Cloy,❑RPeat Cl-,, Sandy loam ❑ Clcy loam. � <br /> Hardpan ❑ Adobe'p Fill Material .._:.'. .:. If.yet,type <br /> (Plot plan, showing size of 'lot, location of system in relation to wells, buildings;etc.f 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 TANK ] size............. ................ Liquid Depth <br /> Capacity Type ..... Maerial..... .......... <br /> No. Compartments <br /> Distance to nearest: Well ............ J Foundation .................•... <br /> • ....................•--•• •-•-•--....__.... Prop. line . <br /> LEACHING LINE [ j No. of Lines ................. Length of each Stine..................:........... Total Length ............. <br /> 'D' Box .A----....-Type-Filter_Material . . Depth .Filter Material <br /> Distance to nearest: Well <br /> Foundation_:....... ... Property-Line .: ........... ........Well . <br /> SEEPA lT [ depth ' .-......._..-.----- Diameter ................ Number ...........I——........... Rock Filled Yes ❑ No {] <br /> Water.'Table Depth ................................................Rock Size ....... ................... <br /> . <br /> Distance to nearest: Well _.....--"....- Foundation <br /> ....:...........•... Prop. line <br /> REPAIR � ..................... <br /> /ApDITION#Prey.-Sanitaition Permit# .................... <br /> ........... Date ................. ...............•) <br /> Septic Tank (Specify Requirements) ".:............ - _ <br /> •D. l Field'(Specify-„Regvirernentsl ----• t".. ---- -----------•. -----•---•---- . <br /> 'Disposal f <br /> .-..---- <br /> -_. --_ . " • .. ”-___. ..._--.____.... - - <br /> ... --....---•• -•--......................---...'................................... <br /> ._--_"" _." -----.-- -.--..-..--- . -........... --------- ._... <br /> j (Draw existing and required addition on reverse side) . y <br /> I hereby certify that I have pireparecl 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 Joaquln Local Health,District. Home owner or Iicen- <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 /> as to become subject to Workman's'Compensation laws of California." <br /> Signed <br /> ----- <br /> ----------- Owner <br /> BY - - -- ----- -Title <br /> -.." <br /> (If of er th wner) <br /> F_0 -DSP MENT E ONLY <br /> APPLICATION ACCEPT D B ----- _ <br /> ---------• DATE . : ..:' <br /> BUILDING Pi=RMIT`l55lfED _...' -------• ----"... _. ....... <br /> - -- <br /> . .. ............-.---------•------. ---- ....----------DATE -.. .......................... <br /> ADDITIONAL COMMENTS ---- ------------- --------- r <br /> ------------------------••-•----•---..._. ----- --. _.....---...--•- .............. <br /> 4c,:.............. <br /> _---_--- <br /> ..-•------- -•--------_-------------------- <br /> Final Inspection by: - •---- ----- ------ '! ------- <br /> EH <br /> -- .... <br /> ------- .. ......Date ............ . <br /> - ---------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M <br />