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OFFICE USE: <br /> APPLICATION FOR SANITATION `PERMIT <br /> --- . _r_J <br /> .............. ................ Permit NoJ7`" <br /> (Complete in Triplicate) <br /> This Permit Expires 1 Year From Date Issued <br /> Date Issued <br />........................................................ r <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 ADDRESSAOCATION /lff/d!l G CENSUS TRACT .......................... <br /> Owner's Name ../"7..*....._�:U.1: 1. ------- -------------- ----------------•-•---- ..........................................Phone .�� .P�`.Q5 ... ....... <br /> Address . ...... ................................. <br /> ��r��- ------��.. �_��a........ cit '��1 f�.D,x'� <br /> Contractor's Name .........................:......... <br /> --------------------License #c�,2 - ..._ Phone� .1����G__... <br /> Installation will serve: Residence Apartment House❑ Commercial ❑Trailer Court 0 ' <br /> Motel ❑ Other _..... ....... ------ <br /> A.C 1 <br /> Number of living units-_/....... Number of bedrooms _......Garbage Grinder ...._�.-.... lot Size ..... . ...... ........................... <br /> "Water Supply: Public System and name ..._..,�.Q.l yl G ----�/.g-1 •_M..L��S ./Zr.�. ----------.................Private ❑ 1 <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Clay ❑ Peat❑ Sandy Loam,[ Clay loam ❑ i <br /> Hardpan C] Adobe ❑ Fill Material .......-.-.. If yes,type ............................ r <br /> (Plot plan, showing size of lot,.location of system in relation to wells, buildings, etc. must be placed on reverse side.) I� <br /> NEW INSTALLATION: {No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ ] SEPTIC TANK 1. I Size................................................ Liquid Depth ..._ ................ <br /> Capacity .. ... .......... Type --------- ----- Material................ No. Compartments ------ _---.... _-- q1 <br /> Distance to nearest: Well .. ---------........................Foundation ...................... Prop. Line ..................... _j <br /> LEACHING LINE [ ] No. of Lines ... .............. length of each line............-......... ..... Total Length ............................. <br /> 'D' Bax .._... .._ Type Filter Material.--------------------Depth Filter Material .._._.......------.............. <br /> Distance to nearest: Well ......................... Foundation Property Line .....--.-- .........� <br /> SEEPAGE PIT { j Depth .. ...... .......... Diameter ................ Number ----- --------- Rock Filled Yes ❑ No ❑9 <br /> Water Table Depth ----- .................. .............stock Size ................. ------........ <br /> Distance to nearest: Well ----_--------------------- ...........Foundation ........-..-.------- Prop. Line ...................... <br /> i ) <br /> REPAIR/ADDITION{Prev. Sanitation Permit# ............................................ Date ________..._......._..____._....- <br /> Septic Tank (Specify Requirements) .............-C' .. _ ....... /t------------ -.o............................................_.................. <br /> Disposal Field (Specify Requirements) ..-..--•-----------------------_ ---------•----- ........................ .......................................................... <br /> ........................... .................... ... .....- . . . ---- --------- ...................-1.......... ........................... <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 RulI's 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, I shall not employ any person in such manner <br /> as to become subject man' mpensation laws of California." <br /> Signed .:.. ... .. -•-•---•---- -------� Owner <br />' -- ----------------------------------------------- Title . ...... . ......... ................. <br /> I (If other than owner) <br /> FOR DE ARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ... .�..'... ._'._. ...._... ... ---•---- ..... --•..... -------------- DATE ... '-1... .... ............ <br /> BUILDING PERMIT ISSUED ......... ...........................DATE . . -----..................----............_. <br /> ADDITIONAL COMMENTS _.._..._ ---------------------_ .................. - -----------.-.....-...........-_......------.-.._._-..........................' <br /> ......................._'.-•-------..........._.--......._.._...- .............................................. ...........--•-----------...............__.................... <br /> k ...................... .............. _.... _..... ................... . . ----................ ---- ----- � _ ....._.._. <br /> fmat Inspection by:C �e •------------- Date .._ `-: .._:__ _ <br /> k. SAN. JOAQUIN LOCAL -HEALTH DISTRICT„ <br />