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FOR OFFICE USE. <br /> APPLICATION FOR SANITATION PERMIT <br /> . ....... ........................................... (Complete in Triplicate) Permit No. ..7 7S <br /> y� <br />•-•----- ...............-•-•-..-.•.• • .. ................. This Permit Expires 1 Year From bate Issued Date Issu% ed ... <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 mode`in compliance,,wA'County Ordinance No. 544 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATI .. ... <br /> Owner's Name <br /> CENSUS TRACT'-----,.....:.• <br /> Address __....-. _ .. . .-- <br /> City 4/, /� -. f <br /> Contractor's Name .. ... .....License # . .V:sg 9 phone <br /> Installation will serve. ResidenceDkApartment House E0 Coi mercial []Trailer Court ) <br /> -Motel 0 Other _.. ...... <br /> Number of living units:.. . :. Number.o{ bedrooms s e� ` <br />'. � g l -- . .._....Garbage Grinder/�Q.._ Lot Size (,��P' _____________•. ; <br /> *'Water Supply: Public System and name: ._ ............ <br /> ...........--•.......................... ............. .......Private,] <br /> ,Character of soil to a depth of 3 feet. , Sand 0 Silt 0 Clay 0 L;Peat(] Sandy Loam Clay Loom [:] <br /> f _ <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.) r <br /> -ANEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer,is available within 204 feet,) <br /> PACKAGE TREATMENT [ SEPTIC TANK 5ize...•................... . <br /> -------- Liquid Depth ............... <br /> ins.----...ate- _—,�_-----.._,,._+�� • °` . <br /> Capacity .: TYPe•/--�-� ..- Material..- .. No. Compartments <br /> t� --------- <br /> Distance to nearest: Well - -.. ...... ............_...Foundation .. .......---_----- Prop. Line ...................... <br /> - T .;.-. .. <br /> {LEACHING LINE [ ] No. of lines _ , --.. __-- Length of each line ... ...... ... ...... Total Length <br /> D';86x r°..a.A - Type Filter Material --------------------Depth Filter Material .......... ._..__-3•_••- <br /> Distance o Barest: Well ------------------- Foundation --------------- Property line ; ...... 01 <br /> SEEPAGE PIT [ ) Depth ri.f t __---- _ Diameter ------------ ... Number ..... Rock Filled Yes [j No C] <br /> Water Table,Depth -----------•--•------------------Rock Size ---................... <br /> .......--. ` i <br /> Distance to nearest: Well -------------------- _._.-------..Foundation -................... Prop. Line..--'_.......... <br /> I � •r , <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ---------------------- ........•- <br /> . Date <br /> -t-e ----.-----.-.------ <br /> Septic Tank (Specify Requirements) ---- - -. <br /> Disposal ••-•-•----...-.) Y fn`.; <br /> i <br /> Field (Speci{ Requirements) -- ,/�:� ---.-----Ze�,---� <br /> - - <br /> -- ----- --------- ----.- ......... •-•--....' . <br /> _ . ............... <br /> - <br /> . ...... . --- ---------- . ........ ,_..T .- <br /> (Drdw 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 r <br /> as to become subject to Workman's Compensation laws of California." !. ` <br /> Signed ..................:..... Owner w W- ow--� <br /> By Title . <br /> (If oth an owner} 0 <br /> USE ONLY <br /> - FOR DEPARTMENT <br /> APPLICATION ACCEPTED BY ._.. . -. <br /> ----•-----.. ..-- . •...-. .----------- ... DATE <br /> BUILDING PERMIT ISSUED . DATE <br /> ........ _._.. <br /> ADDITIONAL COMMENTS -------------­------- <br /> ........ ..... - - <br /> ...... <br /> .----•--•-•...............­............. ----- .............. <br /> ...-- --... <br /> •.................................... <br /> .................... .-----......._...-----....---- ... .................. ..._..---....... ........ .Final Inspection by: ..... .... .. . Date ..... . . ... <br /> -------------•--.----_- .-----•- •-••--------------•--- -------------- �.� . <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 1-3 241-'68 Rev. 5M r 17') z v <br />