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w lOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> ....................___.................. <br /> Permit <br /> _1Complete in Triplicate) <br /> h <br /> ................................._.._..._...._.•......... This Permit Expires 1 Year from Date Issued <br /> Date Issued .4:-!:Z( <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 Cou ty Ordinance o. 549 nd existing Rules and Regulations: j <br /> JOB ADDRESS/LOCAT .. ,� /�,. CEN TPA <br /> CT 1... . �� I SUS CT <br /> .._._ <br /> Owner's Name ----------•------•-----. --- -•.........................I..............----•...Phone .........:........----.............. <br /> Address <br /> i City ... ......... . ..•--.._.•-_ .......................... i <br /> Contractor's Name ... ----------- --- ----•- ..... ...............................License # ........................ Phone . 146 <br /> Installation will serve: Residence❑Apartment House Commercial OTraller Court 0 <br /> Motel ❑Other.---.._. .................................... <br /> Number of living units:.... ------ Number of bedroom--.-Garbage Grinder ------------ Lot Size ... .... .I...... . .. ..........Q <br /> Water Supply: Public System and name ------- ..............................----------•........_...................................................Prlvat <br /> Character of soil to a depth of 3 feet: Sand b Silt Q Clay ❑ Peat o Sandy Loam o Clay Loam ' � N <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.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted If public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK I ] ' ..... Liquid Depth <br /> - Size....-•---------------------------------•-•- ------------•-............. <br /> Capacity ----------•----•-- Type •-------••--•....... Material---------------------- No. Compartments ----•--- ............. <br /> Distance. to nearest: Well ...........................:........Foundation ..................:... Prop. Line ...................... <br /> LEACHING LINE [;] No. of Lines ---.._._..0._.A.------.- Length of each line--............................ Total Length ........ ................... <br /> 'D' Box Type,Filter Material ...Depth Filter Material <br /> Distance to nearest: Well ........................ Foundation -----------I............ Property Line ........................ <br /> SEEPAGE PIT [ j Depth -- _--... Diameter ................ Number ............................ Rock Filled Yes ❑ No � <br /> Water Table Depth ...__..._--•--•----•-••--------------•--•---• .Rock Size ...... ......................... <br /> Distance to nearest: Well .....•..................................Foundation --.................. Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# --_--.------ ........ Date ..................................) <br /> Septic Tank ESpecify Requirements) -gi�----•: -------•--:. .................. ........................------------------- <br /> Disposal Field (Sp if Requirements <br /> �� <br /> _ ._ ---------- --. --- ------------------ --- <br /> --------..4 ....... <br /> . <br /> ............................... <br /> raw existing and required addition on reverse side) <br /> I hereby certify that 1 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:Distdct. Horne 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, 1 :hail not employ any person in such manner <br /> as to bec me subject t orkman's Compens on laws of alifornia." <br /> Signed -- '= ---•- - ---- ----•-- ------------ <br /> By <br /> ----- -By ----------- ----------------------------------------------------------- -------- Title <br /> (if other than ownerl <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY --- --•-------------------•-----..------•---••-•------ ------------._........ DATEt ........: <br /> BUILDING PERMIT ISSUED __-- DATE . <br /> ADDITIONAL COMMENTS -w!' ---- .�vft--,�,[. ,c.� _Ji '- / rof ! ..�..._ <br /> ---------•-••---- --------------------- -----•-----•-------- ----------- -------------------------------------- ---------------- <br /> --------------- ---•----------_--_----..._..._ - r� <br /> FinalInspection by- -------------•• F------•----- ------------=---•----...---=--•--............------...........------. ------Date . f ----------------- <br /> EH 13 2h 1-68 Rev. 5l SAN JOAQUIN 'LOCAL HEALTH DISTRICT 8/711 3M <br />