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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) <br /> Permit No. . �.-. Cy <br /> ................. This Permit Expires 1 Year from Date Issued Date Issued ..1......_... . � <br /> Application is hereby made to the San Joaquin Local Health District for a permit tb 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 .-. A <br /> -----.��-.t��t.��..f3�.�.�...._./.V._.*...��y...�1.........CIrNSUS TRACT <br /> .......................... <br /> r <br /> Owner's Name ... ---------------------.-........ ................................... Phone <br /> 11 r ��jj <br /> Address - .... --•--- . ...... ....... City ../Ocel`.......................................................... <br /> Contractor's Name .. �`-C'4...s �G °'U 'Q!!?L ��4'` ................license # .� ' .�.. Phone <br /> Installation will serve: Residence [Apartment House Commercial❑Trailer Court E) N <br /> Motel ❑Other ............................................ <br /> Number of living units:-..__.------- Number of bedrooms .._-__-.Garbage Grinder ............ Lot Size ...............•.............................. <br /> Water Supply: Public System and name ---.._........... .Private ❑ . ` <br /> Character of soil to a depth of 3 feet: Sandy Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ❑ Adobe 0 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 fest,} % <br /> PACKAGE TREATMENT [ ] SEPTIC TANK f l Size......•............................... --------- Liquid Depth .......................... <br /> Capacity __J ._ Type tPACAWSt MaterialdtW_-St+4_TT No. Compartments ...................... <br /> ` 1 <br /> Distance to nearest: Well ....................Foundation ............ Prop. Line --�P.....:....... <br /> k <br /> LEACHING LINE ( ] No. of Lines ....3--------------- Length of each line------<?a........... Total Length ..................... <br /> 'D' Box ..?/.----- Type Filter Material .JAZ-..-_._---.Depth Filter Materia! --_.�........................ `ll <br /> Distance to nearest: Well _�f a--_---- Foundation .�..__._.. Property Line 35- `......... <br /> SEEPAGE PIT [ ) Depth -------------_-... Diameter ................ Number ............................ Rock Filled Yes ❑ No (3 <br /> Water Table Depth ............................. ..................Rock Size ................................ <br /> Distance to nearest: Well ----------------------------------------Foundation .................... Prop. Line ...................... <br /> REPAIR/ADDITION lPrev. Sanitation Permit j# ---.----.---................................ Date ...............-............. <br /> -•-••) <br /> Septic Tank (Specify Requirements) --- ............. •----•-•-----------------........--...............--............-............................. <br /> Disposal Field (Specify Requirementsi --------------............................. ........................---...-.................................... ....... <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 San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health:District. Horne owner or Ilcen. <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 /> Sign _ _ Owner <br /> -------------- --------------•- <br /> BY � �. .n: <br /> (If other than owner) �----------------------- Title ----...-- _ <br /> .--.._._...----...-- . ...._.. .._..._...---------- <br /> _ F5DR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY _ ------- - --- , DATE <br /> BUILDINGPERMIT ISSUED --------------•- ------------------------------------------------ -•------------DATE ..-------------•--.........-----........__. <br /> ADDITIONAL COMMENTS --------------------------------- --------- •_... <br /> ................ .....................----------------------------------------------------------- .......................... ...................... <br /> --------------- ----------------------- -•--•--------•-----_ •----- ------ <br /> FinalInspection by: .............. -------- ----------------------- ------- ------••-------------------._..Date _ .. <br /> EH 13 24 1-68 Rev. 5m <br /> N JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M <br />