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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT G-�f 3 <br /> Permit No. .: _-------•--•••• <br /> .................. (Complete in Triplicate) I <br /> a—is -? <br /> ........ Date Issued ./.................. <br /> This Permit Expires Ii Year From Date Issued <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/L TION LJ'-7'3 T .... 1 .,.. ... --•..........................CENSUS TRACT _..... ---------- ........ <br /> Owner's Name .. .....................................: <br /> Phone .......... <br /> Address . �. .�. City .. ........ . ..r:k-l..........-•----.... ....................... <br /> Contractor's Name _ '",(tea--- --....License # .,/f�.r .. Phone . .-._..................... <br /> '�" -�`' <br /> Installation will serve: Residence Apartment House❑ Commercial _]Trailer Court ❑ <br /> Motel []other ... •------ <br /> Number of living units.,,./ Number of bedrooms .3------Garbage Grinder ............ Lot Size ••••••. <br /> Water Supply: Pub]icSystem and name ------------------------...........•..........................................................................Private r <br /> Character of soil to a depth of 3 feet t Sand n Silt.-E) Clay E] Peat❑ Sandy Loam C1 Clay Loam ❑ <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 Conk or•seepa it permitted if p blit sewer is available within 204 feet,) <br /> l ♦ l S . Depth ----�...............:v <br /> PACKAGE TREATMENT [ ] SEPTIC TANK[ S 11 ize.- - ---/ -fir--- - - ..._.... Liquid <br /> F -.. Material. �--� _ No. Compartments �.... --•-•-Lr <br /> i Capacity l�b..b.. _:.... Type �-�- _ <br /> Distance-to -nearest: Well .���9........................Foundation ......... Prop. line ..........�........y <br /> .r'..' ... Length of each line ..` `'. /---..._.-- Total Length ........................_..p <br /> LEACHING LINE [ No. of Lines .. <br /> 'D' Box ... ..... Type Filter Material ....; .. ......Depth Filter Material ... .................. <br /> -v... Property line :'� ...... <br /> Distance to nearest: Well ._._..� -- ----- Foundation ��� p �Y •--.-••••--•�• <br /> J ---... Diameter ---=3.'.---- Number ...---- �7--- --.... Rock Filled Yes �No <br /> SEEPAGE PIT ["'j/ Depth r � <br /> ..., . <br /> ..........Rock Size l <br /> "'Water Table Depth G.tp <br /> Distance <br /> to nearest: Well .....- •6- - ---•._. -----------•..Foundation ..�.. ...�....---- Prop. Line ..`...--....__ <br /> • <br /> REPAIR/ADDITION(Prev. Sanitation Permit# --------- ...... ...... Date ----------------------------------} <br /> i Septic Tank.(Specify Requirements} ........ .................... <br /> Disposal Field (Specify Requirements) ----- --------- <br /> w <br /> • --------------- ............ , ........ •---------.. .......------...... ........ ..-- �-------------- <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 San Joaquin Local Health District. Home owner or licam <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's Compensation laws of California." <br /> Signed .... . .... .... ......... ...... - -------- Owner <br /> - ---- - <br /> If other than owner] <br /> f <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ....C.... .. ......................._.,... DATE ...IQ .�. .. ...._... <br /> BUILDING PERMIT ISSUED ......- - --.-- --............ --•.................................DATE ... <br /> ADDITIONAL COMMENTS ----­---- --•- . .........- -•............................................ . -• <br /> ................ .-.... ----•------ .----._....... .............. . <br /> -� -J <br /> ----- ------------------•--------•. ................. .. <br /> . �: .: <br /> Fina! Inspection b ..........bate .. . .. <br /> py: ........... ...... <br /> I + SAN JOAQUIN -LOCA(„HEALTH DISTRICT, <br /> 172 3 1\1 <br /> ;j z <br />