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Ai-. &ICATION FOR SANITATION PERMIT <br /> Permit Na. <br /> lComplete In Triplicate} .... ......... <br /> This Permit Expires 1 Year From Date Issued Date Issued .1.... ...... . <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 /> ^� • n1 <br /> JOB ADDRESS LOCATION __ QOr�... � �._.e:.-.- J I6�-�.1 ►h CENSUS TRACT <br /> / o� ... r.... ... ..... .. ._ ................ <br /> .......... <br /> Owner's Name ................. _4/.'!!_�... A ..tr fi.di.0 S.....................................................Phone .-..... .......................... <br /> Address ... ...... ..._ .... .... s.Q :G'._... ............................. ....... City ........................................................................... <br /> Contractor's Name .......... ---•--•.....:................................................••----•...License r# ..................----.. Phone .............................. <br /> Installation will serve: Residence PKApartment House 0 Commercial ❑Traller Court 0 <br /> Motel ❑Other ............................................ <br /> Number of living units:---./..-.- Number of bedrooms ............Garbage Grinder ............ Lot Size ............................................ <br /> Water Supply: Public System and name ---.......____.....................................---------:...............:..................-•--......Privaie� <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay 0 Peat❑ Sandy Loam ❑ 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 tank or seepage .pit ,permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT I ] SEPTIC TANK I ] Size------------------------------------------------------------------------------- Liquid Depth <br /> Capacity -------------- -_- Type .................... Material...................... No. Compartments ..................... <br /> Distance to nearest: Well ..foundation .. Prop. Line d <br /> LEACHING LINE [ ] No. of Lines ----_--- ------ Length of eachline............................ Total Length .......................... <br /> 'D' Box ............ Type Filter Material ....................Depth Filter Material .......................................... <br /> Distance to nearest: Well ............. Foundation ................ Property Line ....................... <br /> SEEPAGE PIT [ Depth -------_----------- Diameter ................ Number ............................ Rock Filled Yes ❑ No , <br /> Water Table Depth .:..Rock Size ..............:.. <br /> Depth ............. ............................... ......-•------- <br /> Distance to nearest: Well ................................._--..Foundation ..........__........ Prop. Line ......................C <br /> REPAIR/ADDITION(Prey. Sanitation Permit# ........--------------.---..............._. Date ............................) <br /> Septic Tank (Specify Requirements) - -. • ............ ..............� <br /> Di s sal Ii Id (Specify Requirements) i e_... ..._. .._ r .. <br /> 2 2 X <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. Ham* owner or !icon✓ <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 becom subiect to Workman's Compensation laws of California." <br /> Signed ._. .. ._ _. Owner <br /> BY --------------- ........................ Jisle. <br /> (if other than owner) <br /> F 0 D ARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY --------- . . DATE `d.l - <br /> BUILDING PERMIT ISSUED . DATE ------•----•-•----_---- ------__...... <br /> ADDITIONAL COMMENTS ..--- C� ...... ------------­---- _... <br /> --- <br /> ............ . -•--------•------------ <br /> ------- -------------------------------------- ----- ----- - <br /> ...-- .................. <br /> .... •....... ......................................• ...............-• <br /> p y: ...- --•--�-•_--.............•---------.....-------------- /(1 �°�.... ..........._... <br /> Fina Inspection b ---•.Date .... . . .. . . ... <br /> EH 13 2L 1-(13 Rev. SAN AQUIN LOCAL HEALTH DISTRICT 8/74 3M <br />