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FOR OFFICE USE: APPLICATION FOR. SANITATION PERMIT <br /> �/......... <br /> Permit No. .�T. <br />......... (Complete in Triplicate] t > <br /> , <br /> Date Issued <br /> .............. ...........:i.:..... <br /> This Permit Expires t Year From Date issued 1 <br /> Health District for a permit-to construct and install the work herein / I <br /> Application is hereby made to the San Joaquin Local Hea h <br /> described. This application is made in compliante'with County Ordinance�No. 549 and-existing Rules and Regulations: <br /> ,� .. . .....-...-CENSUS TRACT .......................... <br /> JOB ADDRESS/LOCATION Dlv ....-_ ..l✓•••••- ......... <br /> ... ...� .....� ..... .........Phone ............. <br /> ..�. <br /> Owner's Name .- _ C) ....... <br /> � „ y ? moi. '`! •�.. -......_ .. City'-...C�,� - ........................... ... <br /> Address .-. �..._.... ... -� g <br /> . .- . . � .. _... � .;,� s.. :License # .YPhona............... . ,-�= <br /> Contractor's Name ..-. --�' a <br /> installation will serve: Residence ❑Apartment House <br /> Commercial {]Trailer Court <br /> `Motel ❑Other -------- ............:................... <br /> Lot Size `� �"^�.:....---•--- ' <br /> .....-. . . <br /> -Number of living units:............ Number of 'bedrooms ............Garbage Grinder ._-.-...---- o <br /> Private <br /> Water Supply: Public System and name ......---------------........................................................ ' <br /> Character of soil to a depth of 3 feet: Sand ❑ ilt❑ Clay El Peat El . Sandy Loam 0 Clay Loam ❑ <br /> Hardpan <br /> Adobe-0 <br /> 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`publicsewer is available within 200 feet,} <br /> Size----=-=--•-•---�--......---- •.•`•.---...._... liquid Depth ............................ <br /> PACKAGE TREATMENT [ ] SEPTIC TANK[ - <br /> Capacity -Type Material........ ._._...:: NCompartmentsine .................... <br /> .................. T e ......... <br /> No. <br /> :......Foundation ............ Prop. L ...................... <br /> �• i` <br /> Distance to nearest: Wel! `: <br /> } <br /> No. of lines ....................I... Length .of each'.line.-h_...-----.... Total L eng+ ............... <br /> d <br /> LEACHING LINE [ <br /> 'D' Bax .... Type Filter Material ..:::--.--•_•::-•--•Depth Filter Material <br /> Distance to nearest: Well <br /> . Founclation Property Llne .: f._:=":...:.r <br /> Depth Diameter- <br /> Number .................... ..._.. Rack Filled Yes ❑ No 0Z <br /> SEEPAGE PiT [ ] p '"""'""'--•."• <br /> ---�-^-�� ._Rock Size <br /> V Water Table Depth .....*."", <br /> t .Foundation op. :Line <br /> Distance to nearest: Well """"""""' <br /> REPAIR/ADDITION Preva Sanitation Permit# ...................................... ' Date <br /> ................ .............. <br /> ) <br /> Septic Tank (Specify Requirements) .............................. ......_...:.......-.... <br /> ._.-................. ............ <br /> .._. r ..... <br /> Disposal Field ( pecify Requirements} �- <br /> •-- ....... ......... <br /> -- ......--- -•......................•-•......--•--• -•-......... . . <br /> (Draw existing and required addition on reverse side) - <br /> 1 hereby certify that 1,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 Iiten. <br /> ` sed agents.signature certifies the following: . <br /> 111 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 /> Owner <br /> Signed <br /> Signed <br /> .!-�«-�. —. ,.. -u- .....-.. Title .,1�- .. <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> DATE'.. <br /> APPLICATION ACCEPTED BY <br /> ........ <br /> 4 <br /> BUILDING, PERMIT ISSUED . ... .............................: <br /> ......... <br /> ADDITIONAL COMMENTS . � ..:.. -_ :. ..... .................. ....._...:_ <br /> .f <br /> . .. ...........•---........ ­­ <br /> ............... <br /> ........ .. ........ .. ................... ..........--• -•-... -............. <br /> ...... <br /> .............. ....... Date ... . . <br /> Final Inspection by: - """" "'�� <br /> SAN JOAQUIN LOCAL` HEALTH,DISTRICT <br /> 7/723 M <br /> " 1 0. 9A n_.. CAA <br />