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FOR OFFICE USE- <br /> APPLICATION APPLICATION FOR SANITATION PERMIT <br /> .............. ...... - <br /> ' Per mit No. <br /> (Complete In Triplicate( <br /> This Permit Expires t Year From Date 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. 544 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION ._..:.- .D ..-._./, e. ....................... TRACT .......................... <br /> Owner's NameL;0�Wdle,7 ,. <br /> Phone <br /> ... <br /> Address ........ .cam _.:_... "S.�__ZIly-z-€................................ City <br /> Contractor's Name------- ...........License # Phone <br /> Installation will serve: ResidenceXApartment House Commercial❑Trailer Court 0 <br /> Motel ❑Other............................................ <br /> Number of living units:..-/------- Number of bedrooms ......._:.'Garbage Grinder ............ Lot Size ............................................ <br /> Water Supply: Public System and name <br /> �'4 -•- --- -- <br /> ------•----•. -------------.-................----•.._-_. .... Private 11Character of soil to a depth of 3 feet: Sandt] Silt❑ Gay ❑ Peat❑ Sandy Loam 0 Clay Loam ❑ <br /> Hardpan p 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 [ ) SEPTIC TANK( ] Size......................::_-....................__ Liquid Depth <br /> w r <br /> 4 <br /> Ca aci q a.-•--- Type -----• ............Material--------------........ No. Compartments ...................... <br /> Distance.to nearest: Well ------........... .........Foundation ._ Prop. Line <br /> LEACHING LINE No. of Lines h- <br /> [ l Length of each line............................ Total Length ............................ <br /> Vi <br /> ,� D' Box .............. Type Type Filter Mote�ial ....................Depth .Filter Material ..._.__ _.............. ................... 4, <br /> IGS 6 istance to nearest: Well --------•_ ............. Foundation/5 ........................ Property Line ........................ <br /> 't <br /> EEPAE P T [ ( Depth ....� .......... Diameter ZW,.,ec tr:- Number --------___/-------•...... Rock Filled Yes) No I❑ <br /> Water Table Depth ___--------40.. ._-- .............Rock Size r ......... <br /> Distance to nearest'Well...............••_-_-....................Foundation .......-............ Prop. Line ................. <br /> OEPAIR/ADDITION(Prev. Sanitation Permit# ................ .__---_----•-...----•--- Date ___......._............._...... <br /> } <br /> SepticTank (Specify Requirements) --------------------------------•--• ---•---------- .............................- ..-•--•-••---------••--•................................. <br /> Disposal field (Specify Requirements) ...... ------� ..:................ <br /> --------------------------------------------------------- ........................ <br /> -----------------------------------._....-- --- -----------------------._._..-•---••--......._-_-_-.---------------.._._._._.._••••---•••--...._..---•-••-- <br /> (Draw existing and required addition on reverse side) <br /> I <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 Ilcen- <br /> sed agents signature certifies the following: <br /> "I certify that in the perforniance of the work for'whish this permit is issued, I shall not employ any person in such manner <br /> as to become ub)ect to Workman's Compensation laws of California." <br /> Signed ------- F _ <br /> .. Cr <br /> `---------------------- Owner <br /> By .__.. _-•---------------------•- Titfe _.._(I other then own <br /> DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY --- :------•---------------- ••---- -----------.DATE r.---------.. <br /> BUILDING PERMIT ISSUED -------------------- ------- ---------------- ------------.-_--..- _..DATE - ......._...._..._-......----•---------_- <br /> ADDITIONAL COMMENTS -- .............. ------------­----------- <br /> ­1 - - <br /> •-•---------- ------------------------------------ -••-- -••---------...---_---_. .-._......._.... ,- ••---------..._......-....._.. ........_._..-----_.._._......-.-.......... <br /> ...- <br /> -- ----•••• •- --- -- ......... t <br /> Final Inspection -- - _-- Date .-;;X-/Y1- 7-i <br /> EH 13 2h 1 v. 5M SAN JOAQUIN LOCAL HEALTH DISTRICT 874 3M <br /> i <br />