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t <br /> f FOR OFFICE USE: ". <br /> APPLICATION FOR SANITATION PERMIT <br /> --------------------------------------------------------- Permit No. r' 0 <br /> (Complete in Triplicate} <br /> ---------=---------------------------------------------- <br /> - .- .--�.- <br /> This Permit Expires 1 Year From bate Issued bate 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 made in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> �,J ------ CENSUS TRACT ] <br /> ! J08 ADDRESS/LOCATION-r ---- -- <br /> '-`� <br /> Owner's Name ----71-41061111-1,--- ---------------- ------------------------------= --- Phone <br /> - <br /> Address .ar.-y-4V--- -------�--= A- ----------- --------•--. City <br /> ----- ------------------------------------ <br /> Contractor's Name ------------------------------------------- License # ------- ----------------- Phone ----------------------------- <br /> i <br /> Installation will serve: Residence ❑ Apartment House-E] 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 ❑ w <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam.El <br /> 11 Hardpan ❑ Adobe ❑ Fill Material ------------ If Yes,type ---------------------------- j <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) F <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if.public sewer is available within 200 feet,) <br /> i <br /> PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] Size------------------------------------------------ Liquid Depth -------------..------------ <br /> CapacityType -------------------- 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'I to nearest: Well ------------------------ Foundation ------------------------ Property Line ----------------------- <br /> SEEPAGE PIT [ ] Depth --�r--------___---- Diameter -------------- Number Rock Filled Yes ❑ No .0 <br /> Water Table Depth -hock Size -------------------------------- <br /> I � <br /> Distance to nearest: Well ----------------------------------------Foundation -------------------- Prop. Line ---------------------- <br /> I - <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) <br /> Septic Tank (Specify Requirements) ---------- ------------------------------- ---------------------------------------------------------------------------- <br /> ------------- ---- <br /> ' s""° <br /> I Disposal Field [Specify Requireme ts) -_ •cr�-- - - ---ti- - --- '� .-�------ -------------------- ------------ <br /> I herebycerci that I have prepared red(Draw <br /> this application and required <br /> addition h <br /> --------------- - --- ---- <br /> on reverse side) <br /> certify P P e 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 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 /> i <br /> as to become ubject o Workpan's Compensation laws of California." <br /> Signed -.- ._ ------- --------------------------------------- Owner <br /> By ---- ----------------------------------------- I----------- ------------------------------- Title --------------- ------ ----------------------- ---- -------------------- <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY _ ' ---------- -- -- - ------------------------------------------------- ----------------- DATE 177- f- /------------- --------- <br /> BUILDINGPERMIT ISSUED - ----------------------------------------------------------------------------- -------DATE ------------------------------------------- <br /> ADDITIONALCOMMENTS ---------- ' --------------------------------------- ---------------------------------------- <br /> ------------ ----------------------------- ------------ <br /> ------------------------------------------------------ --------------------------------------------------------- <br /> - <br /> --------------------------------- ------ - ----------------------------------------- ------- <br /> Final Inspection ----.Date :-��-f------�--------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'b8 Rev. 5M <br />