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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ......_.... ............. .... ...... Permit No. . .....~.��.. <br /> (Complete in Triplicate) y <br /> ' Date Issued <br />.• <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�unty dinance No. 544 and existing Rules and Regulations: <br /> JOB ADDRESS/ OC ON 1,9 f- CENSUS TRACT __________ I <br /> Owner's Name . .... ........... ...... ---------------------­­ ----------------- .. .......Phone ... ................................ <br /> Address ........ <br /> .._ <br /> 0 p.�f ................ .-�----- City ... "......-.....--------•----------------•------ ; <br /> Contractor's Name .............. ... . .._.License # i f f.3. � Phone .............................. <br /> Installation will serve: Residence ❑ Apartment House❑ Commercial ❑Trailer Court C] j <br /> Motel ❑Other ... " <br /> F <br /> Number of living units:.....I...... Number of bedrooms ... _Garbage Grinder ------ Lot Size .. ..._.._..-._.__.-___ _..- .._......_ <br /> M <br /> Water Supply: Public System and name .............................. ----•-- - -------------------_:_,......--••--------. .._... -------------.-.Private <br /> Character of soil to a depth of 3 feet:'I Sand 0 Silt❑ Clay ❑, ,Peat❑_. Sandy Loam ❑ Clay Loam ❑ <br /> I <br /> Hardpan Adobe ❑ Fill Materia! _-• -, ...- 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.) O <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> � t 1. � � <br /> PACKAGE TREATMENT [ SEPTIC TANK. _Size.4y .._ ... _.. J(.._,'�..�_..._.... Liquid Depth .-.4................... <br /> Capacity .b°. Type_ .___.___. ........ Material.._... No. Compartments <br /> Distance to: nearest: Well �-.._..._____'_Foundation ....7e0_.�....... Prop. Line ... ..�._.._..._. , <br /> a r <br /> LEACHING LINE [ ) No. of Lines. .0 .(. ...- .._. Length of each line ....:,J ..�.._......__ Total Length _40.0..... .. _ <br /> r . ti <br /> ' Boxx <br /> 'Dn Type FiJfer Material _,.,.. _.R--....Depth Filter Material _.._. ..........:...................... <br /> D' B ._...� <br /> Barest: Well _ _,.. .........�--- Foundation .............. Property Line ... ............. <br /> SEEPAGE PIT 14/ Depth .- ��.,_..._ Diameter _. __.__ Number -:.............. Rock Filled Yes No ❑ . <br /> (Depth _...---.....GO-0---•---- ....Rock Size ...I.�a?X-3---------- � <br /> i. <br /> Distance oWater f n I , <br /> Barest: Well .- 14A ----------------Foundation .-..440.-..... Prop. line ..�......... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# --------------------------------_---------- Date ----.-------.-----.-.-------------) <br /> Septic Tank (Specify Requirementsj .... ..... ---------------------------- <br /> Disposal Field (Specify Requirements) ---- ---------- --- ----------------- .............___...----•- _........ --•------- <br /> ----------------- - ................... .._ ----------------------.-------_--------------------------------- ------------------------- -------------- -•-- <br /> --------- ----- ------ .................4k.!-...-........ . ----- .... ----........ .........-------------------------.... _.. .......- ---.......------ <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 San 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 subject to Workman'sAomponsation laws of California." <br /> Signed .... .._....... .............. ... Owner <br /> By ._ ............. ------ <br /> Title . .... <br /> ....... ...... ............................ <br /> (If other than owner) <br /> Y ACCEPTED FOR DEPARTMENT USE ONLY <br /> APPLICATION <br /> BY... ...- ................. .. .......... DATE .....16.111"17Y. ...---•---- �. <br /> BUILDING PERMIT; ISSUED .... ....--•--•-- -...........DATE �I <br /> ADDITIONAL COMMENTS ............._--...----------------- •--------. ...... <br /> N <br /> :.............. . ---..: --.....---- ' ---- - ---- ----- -- .............._.... . ....... ....................................... <br /> .--- a <br /> -------------- ----------- --- <br /> ------ <br /> Final Inspection b -----.bate .._.�...: <br /> I SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> _E_ H- 13 24 1-'ea Rpv_ 5M 7/72 3 M i <br />