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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ............__.......... ......... I <br /> .............. ..................... -,.(Complete in Triplicate) Permit No. <br /> ........................ ........1".-....... This Permit Expires I Year From Date Issued Dote 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 mode lnc6rfipl!cince'with,County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION ....... <br /> .......... NSUS TRACT ........... <br /> Owner's Name <br /> .......I............... .................................Phone ... ........... .................... <br /> Address -ty .......... <br /> ................................ Ci <br /> ..................... <br /> Contractor's Name <br /> .......... .....License ---- Phone <br /> Installation will serve: Residence 'Apartment House 0 Commercial❑Trdller Court. 0 <br /> Motel-El Other,.........................._................ <br /> Number of living units.--.,/.....i,Nurli.ber of bedrooms-.a bage Grinder Lot Size <br /> Water Supply: Public System,cinbl-name- <br /> ...... ......m-.................... ............ --------------------------------------Private <br /> Character of soil to a depth of4.ieet: Scin�c(X' �S­ilfff -Clay E] Peat❑ Sandy Loom 0 Clay Loam 0 <br /> 7 <br /> Hardpan [] Adobe 0 Fill m6teriai --------_,_ 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)V Size.— ...................... Liquid Depth <br /> 'r. .. <br /> �. ............... <br /> Capacity ------ Type .. rt <br /> .... No. Compartments '2-............. <br /> VY L_15�61 --- Mat <br /> Distance to nearest: Well .... Founclotion-.1111�. ......... Prop. Line ...... (5, <br /> "::;Ie........................ <br /> LEACHING LINE &A No. of Lines ................. Length of each line..,;W------- Total Length .;Zle.............. <br /> ........ _5:7 <br /> TFp�e-'F i I t i r�Ma tdr io V.vvollk6e*Depth,Filter-Material- •=•---------------•-• <br /> Dis Z-01 nearesf.;Wi?ll ....... Foundation ....... Property Line ...2,W--------.... • <br /> SEEPAGE PIT Depth ......................... Diameter ................ Number ........ ........ Rock Filled Yes (3 No C3 <br /> Water Table Depth .........4.......... ._.._..Rock Size .......... ..................... <br /> Distance to nearest: Well ........................................Foundation ............ Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit .1-----­----------- ................. .... Date .............................. <br /> Septic Tank (Specify Requirements) .......... ........-..................... <br /> -----------*....... ......... .................................................... ............ <br /> Disposal Field (Specify Requirements) ................................................. <br /> .......... ----------­------------- .................. .................... ------------------ ....................... ........m-..-.................. ----------------I............... ........ <br /> ........... ................._­.............­.­-------------------------------------------- ---•--------•--•---•--,..-•-•--...... <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 Son Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the Son 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 to Workman's Compensation laws of California." <br /> Signed ................... .. ........................ <br /> ..................... ...... Owner <br /> By ................. - L I <br /> Title <br /> ........ ------ <br /> J I�f er than owner) <br /> FOR DEPARTMENT USE ONLY <br /> . <br /> APPLICATION ACCEPTED BY........ ------------- ---- ............ <br /> DATE <br /> BUILDING PERMIT ISSUED ............ ...... ­ ------------ - - ..... -------------- <br /> ...... ................................................... ...DATE ......I................................... <br /> ADDITIONAL COMMENTS .....................1..... <br /> ............ ...........­.....................................,..--•..------•-• ------------ ----- ...............................-•--••-........-_... ....... - .................. <br /> ............................................................ ............................................... .......................................­... ... ............................. .......... <br /> ....................... --------------­- .......... =-------------..............P�... ... .................................... ............................................... ....... <br /> Final Inspection by: ........ ........... il� ............................ ......I------------------ <br /> ...... ....................................................Date ............ <br /> ---'SAN,.,JOAQUIN <br /> _JQCAL_.HEALTH DISTRICT <br /> E. H.;3 .24 1-'68 Rev. 5M. -71-7 It 7 <br />