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FOR oFFxcl USE- <br /> APPLICATION FOR SANITATION PERMIT <br /> ....y....: ---........................ <br /> (Complete In Triplicate) <br /> Permit No. ................... <br /> 17 <br /> This Permit Expires t Year From Date Issued Date Issued 7:�P._...._... <br /> Application is hereby made to the Son 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. 544 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION I. 6i�-� ��l.n�T ✓ ..-. ..............CENSUS TRACT .......................... <br /> l � - <br /> Owner's Name ...f'YrS...__fj'C _. .,._ Phone ...�.�s � ......._. <br /> ....................................... ... .... ....... <br /> y� ; <br /> Address rZ_g._ . / �G+_. /..f?. i�..................... ...... City _..�./.�'�c .. ............ <br /> ..................................... <br /> Contractor's Name 1License i4E .... Zfhone <br /> ------•--••-•--- ••-------- + <br /> Installation will serve: Residence ❑Apartment House C] Commercial[]Trailer Court <br /> I Motel ❑Ctther ........................................•--- <br /> W <br /> Number of living,units--_-------_ Number of bedrooms ---------...Garbage Grinder .........:.. Lot Size..... ....................................... <br /> Water Supply: Public System and name = ...................•---..............._.._.. -...._.._..._..............................Private ❑ �,. <br /> Character of soil to a depth of 3 feet: SanSM S€It❑ Clay ❑ Peat❑ Sandy Loam o Clay Loam Q r!� <br /> Hardpan ❑ Adobe 0 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 a€lable within 200 feet,) <br /> PACKAGE;TREATMENT [ SEPTIC TANK ] _ Size--.... �_ ........ Liquid Depth ....fz1...�. <br /> Capacity _f, ...... Type --------- material...................... No. Compartments. ��..�:-._._... <br /> 1 <br /> Distance. to nearest: Well 0.....................FoundatI n ...� .._....... Prop, Line ... �................. <br /> LEACHING LINE [ No. of Lines -----3_.....__.__. Length of eacf line..7a _ .............. Total Length ._ ,1: .. <br /> �d Al. <br /> 'D' Box ...,1----- Type Filter Materi�&7Z�__..�i "F€Iter Material ... <br /> �� ....................... <br /> ' — Distance_to-nearest-;-Well :` _ ':_-Fournlution ........................-Prope -Line '- M <br /> SEEPAGE PIT (. I Depth ------------- Diameter .........'.......Number ............................ Rock Filled Yes ❑ No <br /> Water Table Depth .................................... - "Rock Size <br /> Distance to nearest: Well ................. ........ --.....Foundation .................... Prop. Line ....:......... <br /> -REPAIR/AWTION(Prey. Sanitation Permit#:.__.......................•----...._.__'_.'Date ................................ y" <br /> 4 ti t i <br /> Septic Tank (Specify Requirements) ........................... ----------------------------................:........-................................................... <br /> ...... <br /> Disposal Field (Specify Req.uirementsl -•--•-•----•--•--•-------------------------------------- -------=-----------------------------------•-•-•--•-•-•-- ---•--------- <br /> -•--------------------------- -----•- ------------------------L---------------------------.-.................................. -•----------•-------------------------.....------..--....•..--------•--- <br /> � x <br /> ------------------_---------------------_---------------------__„----------------------------------------.----------------............................................................................... <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that 1 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. Home owner or licen- <br /> sed agents signature certifies the following: i - <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 beco a subjec�Workrian's Compensation laws of California." <br /> Signed . �._.... Owner <br /> BY ... --------------- -' -----•-------------------------- Title •---• ' <br /> (If other than owner)', <br /> FO eP-ARTMENT SE ONLY <br /> APPLICATION ACCEPTED BY _-__ ..._..__..__. <br /> - -...---- ---................................ DATE .--• --�� --'-_�-G--.�-----.: .. <br /> BUILDING PERMIT ISSUED ---- ---•---- ....DATE ....---... <br /> -----------•-------•--- <br /> ADDITIONAL COMMENTS -------------------..._...------•-----.-----------._-•---------- -•----------- = <br /> ------ -------------------•--------------..._..----.-•-- ---_ _. .........----•-..•-- .--•---• ....-•-------•-•---------------•.._........... --•-•-------....-- ....... <br /> ---- -----•------------ --- --•-------.-----•-•--------•----._-_---_-------•------.-.._.._.._.. f <br /> F€nal Inspection by: .. . - ---- ------------------- - --------I---•----- ----....- - ......Date ... _..'"L_....f . .............. <br /> EH <br /> 13 2h 1-5 SAN JOAQUIN OCAL HEALTH DISTRICT 8 7 M ' <br /> _ / � 3 <br /> FY <br />