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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> ................... <br /> ••- (Complete in Triplicate) Permit No. -.7.... .......... <br /> _................................................. <br /> This Permit Expires ] Year From Date Issued <br /> Date Issued ..�'.:.�a � <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 :Wade in compliance with County Ordinance No. 544 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATION ..,lv .. t�.-, -r ? -f<< ...-_--• ....... .................CENSUS TRACT ....... .............. <br /> Owner's Name 1L.2.Q , <c-c �._:...._ ...........Phone ...................... <br /> Address ...-...�a �' . .... • •... City - e ..........................................•••-...... <br /> ....----�-- ------ - - <br /> Contracror's Name .. ..... ...... 1.. �_. !i_..,License # ._IZZc. = Phone ._._•__.__•................... <br /> Installation will serve: Residence ❑ Apartment House❑ Commercial❑Trailer Court <br /> Motel ❑Other ............................................ <br /> Number of living units:............ Number of bedrooms ............Garbage Grinder ............ Lot Size ............................................ <br /> Water Supply: Public System and name .................------------------------------------------.................................----..............Private 2-' C�1 <br /> Character of soil to a depth of 3 feet: Sand 1[] Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam <br /> HardpanHardpan ❑ Adobe 0 Fill Material ............ If yes,type ---------------------------- <br /> (Plot plan, showing size of lot, location ofsystem 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 /> Capacity .......... ......... Type --.................. Material...................... No. Compartments ............ <br /> Distance to nearest: Well ....................................Foundation ---------------------- Prop. Line ..................... <br /> LEACHING LINE [ ] No. of Lines ........................ Length of each line--------------------.-------- Total Length ............................ <br /> 'D' Box ............ Type Filter Material ....................Depth Filter Material .._._______.__.._..._.......-_--_-.-_•--._-. <br /> Distance to nearest: Well ........................ Foundation .........._............. Property Line ........ ............... <br /> SEEPAGE PIT [ j Depth ...........--------- Diameter ................ Number ............................ Rock Filled Yes ❑ No [] <br /> Water Table Depth ---------------- <br /> -----••----••--•••--------------Rock Size -----.....................--- <br /> Distance to nearest: Well ........................................Foundation .................... Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ............................................ Date .................................. <br /> Septic Tank (Specify Requirements} ............... -......... ---•--- .............. ........................... ------- <br /> Disposal Field {Specify Requirements} ._ d?h. .. .. <br /> ................. . . - - -------------•-------------•----- ......--- --------------------------- ................................................... <br /> (Draw existing and required addition on reverse side) a <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. Nome 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." 1� <br /> Signed ------------------------ Owner <br /> 1?�-P --•-•- .i•itle <br /> By .................................. ................................ .. .......:............................ <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ............ -------------------------------------------------- DATE ....... ..z7 .... ..... <br /> BUILDINGPERMIT ISSUED .•••................................•-----------•---•------------•-•-....---........•-•....:........••----DATE ........................................... <br /> ADDITIONALCOMMENTS .........................•........---------------•---•----......................_,......----------•---.......--................-._.:..-•------...._............ <br /> -------------•••-•••.....I--------•••-----•- ••••----. •••--•----............ ' .. . ...........,... <br /> -----• --- �if� J <br /> FinalInspection by: ...............Til-•+------•---... •--•---------------------• .............................................Date .. . ... . J <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H.13 24 1-'68 Rev. 5M 7/723s4 <br />