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-FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> {Complete In Triplicate) <br /> Permit No. ..................... <br /> .. <br /> ........................................ ................ ���-� <br /> _....... _-•-- This Permit Expires 1 Year from bate Issued 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 made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION , p <br /> 0LQ----•--•..................................CENSUS TRACT <br /> AddOwner's Name ... . _ — ------rM. ................. .Phone..�:.2�-_� 7._... _`:?�'!4..,.�..��_.,._..........._.....................-. .� ..........-• -•----.......--•--••-- <br /> ress ............. city A,c,�.............................................. <br /> Contractor's Name --- -,---- e... ► ------------------------------------------- ..License # ,5.7.!l_.g.4 ... Phone . 1I <br /> n. <br /> Installation will serve: Residence Q Apartment House❑ Commercial❑Trailer Court 0 <br /> Motel0 Other........................................ <br /> Number of living units:_P_'- --_ Number of bedrooms ..-------Garbage Grinder .Aa.... Lot Size - <br /> i <br /> Water Supply: Pub'iic System and name ................ .....Private <br /> Character of soil to a depth of 3 feet: Sand lo Silt 0 Gay ❑ Peat❑ Sandy Loom ❑. Clay Loam ❑ <br /> Hardpan ❑ Adobe ❑ Fill M6terlal ............ If yes,type............... ............ <br /> (Plot plan, showing size of cot, 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; j Size.....- ..-.-�(�•�.I... ...5 Liquid Depth ,�.��. .! <br /> .... ............. <br /> Capacity .. =d�.d_�._---- TYPe'== '`°r= fj <br /> "'.. Material._.----•-------------- Na. Compartments --...........� <br /> Distance to nearest: Well ':..1_5-'......................Foundation 10-FT ...... Prop. Line SrJ <br /> ....... <br /> LEACHING LINE [ j No. of Lines .2----,--- ---_---- Length of each line... ; ' •J <br /> g -- •--•......... Total Length p <br /> 'D' Box _..�-•-•---- Type Filter Material .�_�A.C,.e_kDepth Filter Material ..Q..1.................................. <br /> Distance to nearest: Well _q-b................. Foundation a.,57......... ...... Property Line _ ...._........... <br /> SEEPAGE PIT { j Depth -------------- ---- Diameter ._....... ...... Number _........................... Rock Filled Yes ❑ No {� <br /> Water Table Depth <br /> -------------------•--------------------•-----•-Rack Size ............................... <br /> Distance to nearest: Well ............................ ..........Foundation -------- ........... Prop. Line ......... ........... <br /> ItLrPAIR/ADDITION{Prev. Sanitation.Permit �- _. .... Date ...:.................... <br /> Septic Tank (Specify Requirements) --------------•-------•-••--------• .. <br /> .. ..........•.. ...................... <br /> Disposal Field (Specify Requirements) _____..............•__•........... .................. <br /> _.._r.....................•--•-•--....------__.___._.--....._.....-........ <br /> f <br /> -------­------------------ --------•----------. - _ <br /> (Draw existing and required addition on reverse sidel <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. Home owner or licert- <br /> sed agents signature certifies the following- It: <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 -------------------- --------------------------- ------- Owner <br /> BY G. o f 014�_----------- ----------------------- Title <br /> (if other than owner) <br /> -- FOR ARTM USE ONLY <br /> APPLICATION ACCEPTED 8Y - ------•--- ----------- - -------- . --•-_. DATE ..,.;. D <br /> ............ <br /> BUILDING PERMIT ISSUED --------- --------------------------------------------------------------------------_-•---.............. <br /> DATE ._..._. _ ._.. ... <br /> ADDITIONAL COMMENTS <br /> ----------------------- --...--------......-. <br /> Final Inspection by: .... __ .---- _ : Date -. . ... <br /> ------------ <br /> 13 24 1-68 1 v. SM SAN JOAQUIN LOCAL HEALTH DISTRICT 874 3M <br />