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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT CSS <br /> ................•...--...--......--...........- <br /> (Complete in Triplicate) Permit No. ..7-....... <br /> .......................................... <br /> " <br /> ................................... This Permit Expires 1 Year From Date Issued <br /> 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 mode in compliance with County Ordinance No, 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION ..-- �1�'. .-...(r....At1- .. •fit .1v ...........................CENSUS TRACT <br /> Owner's Name .Ps..4 . If R.. ...*. .3:....:......................... ----- . ---k----•- .... ...........Phone <br /> Address ....... .. <br /> .�- .... �!-t...... .................... City -----LP . <br /> Contractor's Name .- ` . - J,& __ - License # P. .rV.... Phone . �� --3f�:3�� _ <br /> Installation will serve: Residence M_41'0'rtment House C] Commercial f:]Trailer Court 0 <br /> Motel []Other ................. .......................... <br /> Number of living Units:............ Number of bedrooms' .A.....Garbage .Grinder ............ Lot Size ............................................ <br /> Water Supply: Public System and name ..................................................... ---------- .................................___---Private <br /> Character of soil to a depth of 3 feet: Sand t] Silt❑ Clay ❑ Peat❑ Sandy Loam 0 Clay Loam Q <br /> Hardpan ❑ Adobe g4�-rsli 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 is available within 200 feet,] <br /> PACKAGE TREATMENT [ ] SEPTIC TANK[ ] Size............................. ........ ...... Liquid .Depth ............... <br /> Capacity ............. Type •---•-•............. Material...................... No. Compartments ...................... 1 <br /> Distance to nearest: Well .....................................Foundation ...................... Prop. Line ...................... �� •1 <br /> LEACHING LINE [ ] No. of Lines ------------------------ Length .of each line-------.--- _..- ......- Total Length ......................... <br /> 'D' Box Type Filter Material .Depth Filter Material ...... ............. <br /> Distance to nearest: Well .........................Foundation ------..-_...-.......... Property Line ........................ <br /> SEEPAGE PIT [ ] Depth ----_------------- Diameter .........a...... Number............................. Rock Filled . Yes ❑ No {� l <br /> Water Table Depth .....-•--•-••--••.............Rock Size -----••. ••---...............•- <br /> Distance to nearest: Well ........................................Foundation .-----. ............ Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -...-----------------_-__._ -------------- Date ..................................I <br /> Septic Tank (Specify Requirements) . VL <br /> -- ------------- ...._.- -----•---------• --- <br /> Disposal Field (Specify Requirements) ---- ------ .....h4, - ------.. .--- f ------------- -.-..-•------- <br /> c .5..� -.---.... -------•'....................•---••--------.... .......................------------------------------------------------------------------- <br /> --------------------...........----------------------------------. ----- LI <br /> (Draw existing and required addition on reverse side) <br /> - :P <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquln <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, 1 shall not employ any person in such manner <br /> as to become sub" ct to Workman's Compensation laws of California." <br /> Signed .. .... ----• ------- --- ---- --- <br /> -------- ------------------------------------°:....... Owner <br /> By -._.... . -. ...............+...... Title A <br /> If other t an owner} <br /> R DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED 8Y .. .: .......................... .............................................. DATE ... .................... <br /> BUILDINGPERMIT ISSUED ............. ............................................................' .--..........DATE ........................................... <br /> ADDITIONAL COMMENTS ......................... <br /> • .......................... • •-•--••-•-•--•----...... • ...............••........--•-•--•-----•-•-••---•-- <br /> ..................-•.......... .............•--...... ------------............-- ---------- ........•--•---...--................................................................................ <br /> -....-•-•---------------------------------- -••---•---•.•---------...----•---.....,.....-...... . A .....................-....­...., <br /> Final Inspection bY: � -•----•-------- ---------• -•---...........--•---. ----•- Date ._ �4_...--..... <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H.13 24 `1268 Rev. 5M 7172 3 M <br /> i <br />