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_FOR OFFICE USE: <br /> ------------------------------ APPLICATION FOR SANITATION PERMIY C-_: <br /> ...._ __ . 't x `i .` '` `W % ' _ Permit-No. `'----- ------ <br /> ,. <br /> {Complete itT Tripficatel'" ` r_ <br /> ' -------------------------------------- <br /> i Date Issued <br /> -------_-_------------------------- ---------- - ----- This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct an'd install the work herein <br /> described. This application is made in. compliance with CountyOrdinanceNo. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION ----- -� ----------"r—,__--r /_� / ----------�-------.-CENSUS TRACT <br /> � /.�.............•- TRACT-- --------- <br /> -------------------------- <br /> -_'777a <br /> Owner's Name - ---- elv------------- - ----- Phone �� L�- = c _ - <br /> Address � Tn � c Ci#Y <br /> Contractor's Name -----� �'� ---r _- - -----_--------License#j - / Phone <br /> Installation will serve: Residence Apartment House[] Commercial ❑Trailer Court ❑f 'ter <br /> Motel ❑Other l____________ ____________________________ <br /> ber of bedrooms �____Garba e Grinder <br /> ; <br /> Lot Size ___________________Number of living units:___ _ _ Num Ad_ _/ C! <br /> Water <br /> Supp,{Y: Public System and name --------------------------------- ---------------------------------------- -----------------------------------Private ❑ <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ ! Clay LoamC] <br /> Hardpan 0 Adobes Fill Material ------------ If yes, type ---------------------------- <br /> (Plot plan, showing size of lot, location of system i�_relation ta�wells,_bui.ldings, a"tc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit pe'rmitted if public sewer is available within 200 feet,} <br /> PACKAGE TREATMENT [ ] SEPTIC TANK [ ] , Size------------------------------------------------ Liquid Depth .-_--------------=--,"__-- 0 <br /> Capacity 1-------------- Type ------- 1�, Material---------------------- No. Compartments ------ <br /> Distance to nearest: Well ---------I--------------------------Foundation ---------------------- Prop. Line -----------_.:_-.-_--- <br /> LEACHING LINE [ ] No. of Lines ------------------------ L ne gth lof each line---------------------------- Total Length ;______-___ ---------------- <br /> D' Box -------t---- Type Filter Material#-------------------Depth Filter Material ----------------------------- ' <br /> Distance to nearest: Well ------ --- Foundation -------------------- ° Property, Line <br /> SEEPAGE PIT ] Depth ----___ ---------- '___ --_ Number -----------------------------� ' `Rock Filled Yes No " <br /> . -------- Diameter ------, - ❑ �❑ <br /> Table iDepth --- ..�' ----- `.Rock-Size --------- <br /> Water <br /> Distance to nearest: WeIIY � ___ ____ _______________ 'Foundation --------------------- Prop. Line ___________--_--__--_. <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -----"------------------------- - ------------- Date ---------------------------- <br /> 4wl <br /> Septic Tank (Specify Requirements)]----------------------------------------�------------------------------------------------------- -� : -- _--------------•-- <br /> Disposal Field (Specify Requirements) --------------------- �w--------..G � <br /> �< <br /> -- ---- -�;3 -------------- -------, %7 ----------------------=------------------------ <br /> r. <br /> {Draw existing and required addition on reverse side) _ <br /> 1 hereby certify tha, 1 have prepared this application and that the work will be done in accordancewithSan 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: <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 ----------------------/an <br /> ----------�- - - - ------ ----------------------- ---- Owner <br /> E Title <br /> BY ---------------------------- ---------------------- <br /> Title 1f <br /> (If othene. <br /> FOR DEPARTMENT-L'I�SE'ONLY <br /> APPLICATION ACCEPTED BY - --------------- --- `--- - ----------------------------------- <br /> DATE __g Zj <br /> ---- <br /> BUILDING PERMIT ISSUED ---------- ------------=--------------DATE _------------------------------------------ <br /> ADDITIONALCOMMENTS ------------ --------------- ---- ------------------------------------------------------------------------ -------=-------• ------------------ <br /> i <br /> ----------------- ------------------------------------------ <br /> I <br /> ---------------------------- --------------------------------------- <br /> Final Inspection by: _ ` ---------------Date _ '-�_�------�---------------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 4 <br /> E. H. 9 1-'b8 Rev. 5M <br />