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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ----------------- -------- -- - ------------------------ Permit No. <br /> (Complete in Triplicate) <br /> -----------------------------------------_--------------- This Permit Expires 1 Year From Date Issued Date Issued _:_7 . <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 /> JOB ADDRESS/LOCATION 5 m--- -5 --itid?�'1 Yrs-(- --------- _--------------------------CENSUS TRACT --------------•----------- <br /> Owner's Name ------- -------------------f------ �------------------------------------------------------------------ -------Phone ------------------------------•- <br /> Address --------------------------------- -;�//4----------------------------------------------- <br /> -------•--- Cary - ----------------------- ------- -- <br /> Contractor's Name . .ri <br /> e----------------------------------------- ---------.License # ---------;-------------- Phone ------------------•- --------- <br /> Installation will serve: Residence 4Apartment House-E-] Commercial ❑Trailer Court i❑ <br /> Motel ❑Other -------------------------------------------- <br /> Number of living units:___ Number of bedrooms _---3-_--Garbage Grinder ------------ Lot Size __.___� __,________________________ <br /> Water Supply: Public System and name ------ ------ -------------------------------------------------------- ---------------------------------------Private [ <br /> Character of soil to a depth of 3 feet: Sand'0 Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe' Fill Material ----- ------ If yes, type ___________________________ <br /> (Plot plan, showing size of iot, 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 TREATMENTS EPTIC TANK�[� Size--------------1 -- --------- Liquid Depth .....-,�----------- <br /> __-- -� <br /> Capacity __IC ____ Type Material---L0.MkdtL_ No. Compartments -------Z.......:.... <br /> Distance to nearest: Well ----------I_60_'________________Foundation -----/Pa---------- Prop. Line ---!0<=)_:--__---_ S <br /> LEACHING LINE [ ] No. of Lines __________ _________ g -- t_XY__ Total��Length 6 <br /> __ Length of each line----------- ---_Q�__________________ <br /> 'D' Box ----- Type Filter Material Depth Filter Material __fAS u_____---j4�e______________________ <br /> Distance to nearest: Well ------------------------ Foundation ------------------------ Property Line. ---------- ------------- N <br /> SEEPAGE PIT [ ] 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 (Specify Requirements) ------------------------------------------------------------------•---------------------------- <br /> DisposalField (Specify Requirements) -----------------------------•-------------------------------------------------------------------------------- ---------------------- <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 Son Joaquin Local Health District. Home 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, I shall not employ any person in such manner <br /> as to become subjec to Workm n's Compensation laws of California." <br /> �f <br /> Signed -- ` -----`- � - - --------------------------------------------- Owner <br /> BY --- -- -------------------- --------------------- --------------------------------------------------- Title ----------- ------------------------------------------------------------ <br /> (If other than owner) <br /> FOR DEPAitTMENT USE ONLY <br /> APPLICATION ACCEPTED BY -------- ------------------- p,.,,16^'�-- DATE ------- �Q . -•--- <br /> `t <br /> BUILDING PERMIT ISSUED ----- - --- -----------------DATE ------------------------------------- ----- <br /> ADDITIONAL COMMENTS !7 ---------------------------------------------------------=---•--- -------------- <br /> ---------------------------------- ------------------------------------------------------------------------------------- --- ---- ----- ----------- <br /> FinalInspection by: --------------------------------------------------------------- ------------------ <br /> - 1- _-Date I_-.` _ ------- ---- <br /> SAN JOAQUIN LOCAL HEALTH STRICT C 73 <br /> E. H. 9 1-'b8 Rev. 5M <br /> i <br />