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F0R'OFP10E USE: APPLICATION FOR SANITATION PERMIT . c� <br /> R = Permit No. - ! <br /> ------------ <br /> (Complete in Triplicate) <br /> -------- --- ----------------------- 36 .73 <br /> 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 and install the work herein <br /> described. This application is made in compliances with County Ordinance No. 549 and existing Rules and Regulations: <br /> 1 r: 1 - �- ''•.CENSUS TRACT -5 <br /> JOB ADDRESS/LOCATION _ _._- _ �Q <br /> Owner's Na a - ��.� �------------------------ <br /> - -------Phone -------------------------------•---- <br /> Address --v`�-r_ - City ----- <br /> r -- .. c f <br /> Contractor's Name t�' ------License # ��IF__ Phone ----------------------_ <br /> Installation will serve: Residence ❑ Apartment H use-[] Com cia�Trailer Court i❑ <br /> Motel ❑Other <br /> : t <br /> living units------------- Number of bedrooms ------------Garba_ge Grinder _------.--- Lot Size -.--__------.___----------------_--------.. <br /> Number of g <br /> Water Supply: Public System and name ---------------- ----------------- --------------------------------------------------------- <br /> ------Private <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam ❑ <br /> Hardpan ) Adobe-❑ 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.] t,,I <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) <br /> PACKAGE TREATMENT [ I SEPTIC TANK;[ ] Size----------------------------------------- - Liquid Depth -------------------------- <br /> Capacit ------ Type -------------------- Material---------------------- No. Compartments Q <br /> Distance to nearest: Well ------------------------------------Foundation ---------------------- Prop. Line ----- _-------------- <br /> LEACHING LINE ( I No. of Lines -______---------------- Length of each line.-----.____---------------- Total Length ,_-------------_--_.--:__ <br /> 'D' Box ---I-------- Type Filter Material --------------------Depth Filter Material --------------------.-----------------••-. <br /> Distance to nearest: Well ------------------------ Foundation ---- ------------------ Property Line ----------------- <br /> SEEPAGE PIT [ ] Depth -------------------- Diameter ---------------- Number ----.----------------------- Rock-Filled Yes ❑ No C] <br /> Water Table Depth ----------------Rock Size -------------------------------- <br /> Distance to nearest: Well ------------------ -------Foundation -------------------- Prop. Line ----------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ----------------------------------) <br /> a <br /> Septic Tank (Specify Requirements) ------------------- -------------------------------------------------- - \ I <br /> Disposal Field (Specify Requirements):------------------------------------------- =------------------------- --------------- <br /> ---------------------------------- <br /> ------------ <br /> w <br /> ---- � <br /> el <br /> --------------------------------- ---------------- - ----- <br /> -------`------------------ -- <br /> �x(�Eraw ezisti g-and required addition on reVerse side) -� G <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. Home owner or licen- <br /> sed agents signature certifies the following: <br /> "I certify'fhat,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 ---------------------------- - -- --------------- n --- Owner((�7 q <br /> R <br /> g C Title 7�_--..'� r�Ca-- ------------------ ----------- <br /> BY a ' <br /> --------------------------- <br /> (If other than owner)' <br /> fi FOR .DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED, BY --------------------------------------------------------------- DATE _Y:-� '7-' „ <br /> BUILDINGPERMIT ISSUED ------------ ------------------------------------------------------------------------------------------- DATE <br /> ADDITIONALCOMMENTS - - --------°--------------------------------------- ----------------- ----------------------------------------------------- --------•-•---------------- <br /> ------------------------- ----------•_---------- ------ -----------------------------------------------------------------------•-------------------------------------------------- <br /> ' ---------------------------------------------------------------------------------------- <br /> p <br /> Inspection,: ---------- <br /> x�` _ ------ ---------------------------------------- <br /> ----------------------- _ <br /> I <br /> - ------�-.Data - - --- ------------------ <br /> Final <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'b8 Rev. 5M tN�� <br />