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faOR OFFICE USE: r .� ` 442*APPLICATION FOR SANITATION PERMIT � � <br /> Permit No. -- — <br /> _ _----------- <br /> (Complete in Triplicate) <br /> -------------"-_------------------------------------- <br /> Date Issued <br /> This Permit Expires 1 Year From Date issued <br />----------------------------------------------------------- <br /> Application is hereby made tc the San Joaquin Local Health District for a per to construct and install the work herein <br /> described. This application is made in compliance with County rd•+nance No. 549 and existing Rules and Regulations: <br /> !OB ADDRESS/LOCATlO �.�-�-� �- !- ---- - - r- - - :�►rr- <br /> -A ----- -----CENSUS TRACT -------------- ----------- <br /> Owner's Name - , -----------=-------------- Phone <br /> ---------------- <br /> = Cite -Address ----------.AP -- --.Lcense # / <br /> ��- ----- <br /> �hone <br /> y -4---'tor's Name --___-- -- -- --Contrac <br /> Installation will serve: Residence Apartment House-F-1 Commercial Trailer Court ;❑ <br /> Motel ❑ Other --------------------------------------- <br /> Number of living units-----/------ Number of bedrooms _-- -_--_Garbage Grinder ------------ Lot Size ---- <br /> -------------- <br /> - -R-�. <br /> Water Supply: Public System and name ------------------------------------ - - --------------------- -•--------------------------- -----Private <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay .❑ Peat❑ Sandy Loam Clay LoamEl <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.) f <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) ', <br /> PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] Size------------------------------------------- <br /> Liquid .Depth -------------------- ``rr <br /> Capacity -- Type -------------------- Material---------------------- No. Compartments ----------_---------- <br /> Distance to nearest: Well ------------------------------------Foundation ---------------------. Prop. Line ----------------------- <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 <br /> Number ---------------------------- Rock Filled Yes [] No I] <br /> i <br /> Water Table Depth ---------------------- <br /> ----------------- -----Rock Size -------------------------------- <br /> Distance totnearest: Well ---------------------------------- •----Foundation -------------------- Prop. Line -.-.---.--- -------- <br /> "p <br /> ---------------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit�# ------------------------------------------- Date ----------------•• <br /> Septic Tank (Specify Requirements) -------- ------------------------------ <br /> A- - - -------------------------- <br /> Disposal Field (S ecify Requirements) --� -rt .' - <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 /> €' an Joa uin local Health District. Home owner or ticen- <br /> rdinances State Laws, and Rules and Regulations of the S q <br /> Count Ordinances,Y <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 --- -------------------- <br /> ------- -- --- Owner <br /> By -------------------------------&/K�-- ---- V - ---- - -- --------- Title <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> If <br /> DATE 5 - �' - ' 0 <br /> APPLICATION ACCEPTED BY = --------------------------------------------------- ------------- <br /> BUILDINGPERMIT ISSUED ----------= ------------=---------------------------------------------------------------------------------DATE -.. <br /> ADDITIONALCOMMENTS -------------f----------------------------------------=----------------------- ------------------------------------------------------ -------- <br /> ----------- ----- ------------------------------ ---'c <br /> --------------------------------------------------- <br /> - AQ ' - ---------------------------------------------------------"` <br /> Final Inspection b-- --- a ---- ------------------- - ------------- ---------------------------- .Date --- ",---�- - <br /> + SAN -JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'bB Rev. 5M, <br />