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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ............................I....._._._.._ (Complete in Triplicate) Permit No. . <br /> ---•�••--•• ' <br /> } Date Issued ... <br /> ...................................................... This Permit Expires 1 Year From Date Issued <br /> I � ' <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. 544 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATI r .... <br /> .. ..... .... ...,_'..- - -�[ / . . <br /> t /J 1 .-... CENSUS TRACT ...._ <br /> Owner's Name ...-C; � ' /r` G�� '�.. _- i <br /> t Phone :.. ' <br /> Address ;.._ f .. .- City ................................... <br /> . <br /> Contractor's'Name ,+tj ......---.license ,i�i7. l/-.~f..:Phone �. •G'!... <br /> Installation will serve Residence []Apartment House❑ Commercial C]Trailer Court ) <br /> i ( j Motel ❑Other ,•,.�/ I I • } <br /> 4 <br /> Numbr of diving units- Number Number of b droamsGarbage jrinder Lot Sizeblf... ......... <br /> WaterWater Su I Public System and Home _.- I <br /> Supply: Y !._._._ __ : ................Private)< <br /> Mr <br /> Character of soil to a depth of 3 feet_ Sand D Silt❑ Clay ❑ -Peat 0 Sandy Loam ❑ Clay Loam O <br /> !Hardpan 0 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 /> I <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT ( ]� SEPTIC TANK /ST�ySize...........................................t...- Liquid Depth .......................... <br /> Capacity --, . .. ...... Type -------------------- Material....._ ...... ....... No. 1 Compartments ...... -•• <br /> i <br /> Distance to nearer#: Well . .........:........................Foundotion ............�........ Prop. line ............... <br /> LEACHING LINE ' No. of Lines - .-�-. Length of Each line ..,,?O'.f. _-. .- Totol length .�P. .............. } <br /> 'D',., BoxT e Filtef Material <br /> ` ... yp - --.._.Depth Filter Material :�Y..------...--• ..................... <br /> Distance toinearest: WeIIpZO..11...._.._.._ Foundation ...............'Property line ti$ ..........•.... <br /> SEEPAGE PIT Depth Diameter ._.-. Number . .off.................. Rock Filled Yes j No (] <br /> �...-.-. ... <br /> Water Table Depth .-__ / -�................................Rock Size ...�..� <br /> I / �/ <br /> Distance to nearest: Well ... Q.s��......................Foundation ZV.., ,-..... Prop. line __ ..___.-__• .. i <br /> REPAIR/ADDITION(Prev. Sanitation Permit ............................................. Date ...._-...............:....,....... <br /> } <br /> Septic Tank (Specify Requirements) ............. . <br /> - --------- <br /> Disposal Field (Spe 'fy Requirements) ,, ,Fes..--._, .. .._.L -�c9'C�...__ . .___ ............. <br /> _.. ....... . ..... <br /> ............ . ............................................................................ .. . ......_......_.. ..--........................................ <br /> j (Draw existing and required addition on reverse sidel <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. Horne owner or licen- <br /> sed agents signature certifies the following: , - <br /> "I certify that in the performonce of:the work for which this permit is issued, 1 shall not esnpley any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signed .:........... ....... ' i.... ...... .... . ----------------------- -_ Owner <br /> i <br /> BY .. ........:" Title .... ............ .. .. .. � . . _..... _. <br /> (.. . . <br /> -- - If other than owner- <br /> " FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ------- - rte.-,!�....^--- ► 't1..r....... DATE ..25`......'.7...4. <br /> BUILDING PERMIT ISSUED .. ........................ ..............DATE , ......................................... <br /> M <br /> ADDITIONAL COMMENTS ....... .... ..}... ........._-.......................................... <br /> ...... ­-----------------­--------**............ <br /> ............................................................................i- ............................... <br /> ........... <br /> .............. .............•----------• --------------------------------- <br /> .... .. ................:... ...... . . .. .... <br /> gl Inspecti n by: .. i... Date ............y.... _ ....... _ .. <br /> 7r - SAN JOAQUIN' LOCAL HEALTH DISTRICT, <br /> / ��i 1 r2 V1.'AA Do.. SM 7/77 1 w <br />