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FOR OFFICE USE. No -r— 0�C/ <br />APPLICATION FOR SANITATION PERMIT <br />_RC F <br />'r. AID lZomplete in Triplicate) Permit No. <br />.......... ......................... I .............. This Permit Expires I Year From Date Issued 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 />QZSI -5, <br />JOB ADDRESS/LOCATION .. ....... CENSUS TRACT <br />....... ........ .. ......... ...... _ ............Phone. <br />Owner's Name /P1 .......................... <br />........... <br />I 4�e- <br />Address ....g.oz ..... ­... ... ... ....... ...... I ...... ........ City.,.:. ................ ­ ............. <br />Contractor's Name ............ ... .......................... ....... ...................................License # _ ...... ........ Phone ----------------- ............ <br />Installation will serve: Residence[] Apartment House 0 Co ercial []Trailer Court <br />Co <br />............... <br />Number of living units: ...... Number of bedrooms Garbage Grinder Size <br />..................... <br />Water Supply: Public System and name ..... .............................. . _ ------------------ ------------------ ------- .......... ............. Private 8— <br />Character of soil to a depth of 3 feet: Sand 0 _Silt E] Clay. 0 Peat F1 Sandy Loom Clay Loam-0— <br />Hardpan F] Adobe Ej 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 tank or seepage pit permitted if public sewer 's availab)e within 200 feet,) <br />... Liquid <br />PACKAGE TREATMENT SEPTIC TANK f Size ---- _7 Depth --------- ------ _ ...... <br />Capacity Type ... ............... Material.. No. Compartments ................... i <br />Distance to nearest; We -7 1 <br />'../ -------------- Foundation --- Prop. Line <br />LEACHING LINE No. of Lines Length of each line Q....._......_. Total Length Z 4 -a ............ <br />'D' Box .. >5o Type Filter Material .................... Depth Filter Material .......... ................ <br />Distance to nearest: Well ... �!A./ Foundation . ..... Property Line ........ <br />SEEPAGE PIT Depth . --- Diameter ................ Number .............. ....... Rock Filled Yes ❑ No C) Iii <br />Water Table Depth --- .. ....................................... Rock Size ......... ----------------------- <br />Distance to nearest: Well ...................... ....... ---------- Foundation .... ........ . Prop. Line ...................... <br />REPAIR/ADDITION (Prev. Sanitation Perrnit# ......... ................................ .- Date .................................. <br />SepticTank (Specify Requirements) ... .................................... ........... ... .................................................... I ....... ................... <br />DisposalField (Specify Requirements) ............ ...................................................... ...................................... .......... ... .... ...... <br />............... ....... .............................. ................................................ ........ ........... ...... ........ -11-1 ...... ................. <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 Son Joaquin <br />County Ordinances, Slate Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- <br />sed agents signature certifies the following: <br />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 smbjeti to Workman's C,,mp,,n�i� <br />n laws of California." <br />Signe( .... ......---------------------- Owner <br />By"''.. ........ ...................................... * ................. ..... * .............. . Title . ... .... ............ ... I................ ..... <br />(if other than owner) <br />FOR D4FARTMENT USE ONLY <br />APPLICATION ACCEPTED BY ....... C.... ....... 40' ........ -1 -------- <br />..... I g-l� - - -.1 ........................................ DATE .. _ 7 �� - '/ '/ <br />BUILDING PERMIT ISSUED ...................................... ............... _DATE ... ............ ----------- __ .......... <br />.......... .... ............... <br />ADDITIONAL COMMENTS ...... ............... ....... ...................... .................... <br />................. <br />................................. ........... - -- ----- --------- ........ ............... *­'­ ..... ... .................. <br />.................... ......... ....... I .............................................. !,.. ........ : ..... I ............ .................. ­ ...... ­.: ........... <br />......... ..... .. ...... ...... ............... I ................... ........................... -- ------- 17 . . ........... <br />Final Inspection by; Dole-_ .......... <br />- -- ------- ------ ............... .................................. <br />SAN jbAQUIN LOCAL HEALTH. DISTRICT <br />