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L APPLICATION FOR SANITATION PERMIT <br /> 7S <br /> --- --- .............................. Permit No. . <br /> (Complete In Triplicate) �7 _ ;...... i <br /> .. T �-/7 7f <br /> This Permit Expires 1 Year From Date Issued ©ate 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 unty Ordinance No. 549 and existing Rules and ReVulatlons: <br /> .108 ADDRESS/L TI .� :/. � ....`...,!. ... . ... ......................CENSUS TRACT. � <br /> v .. Phon/- <br /> Owner's Nance .... ... ....-- .. . .............. .... .,.. <br /> ow <br /> Address T 1.' .... ............Cityc ........ ...... _ t <br /> Contractor's Name ....................................'i ............. ............................License t 1. ...... Phone �'...��6.... ....... <br /> Installation will serve: Residence❑Apartmen�_Flou:a omme?a �a1rgur ,�j <br /> Motel Q Other.... ..... . ............{.'......... L f J <br /> Number of living units:............ Number of bedrooms ............Garbage Grinder ............ Lot Sloe ............................................ <br /> Water Supply: Public System and name ......................................................._....................................................Private❑ <br /> Character of soil to a depth of 3 feet: Sand E3 Silt❑ lay ❑ Peat❑ Sandy Loam ❑ Clay Loam <br /> Hardpan❑ Adobe 4Fill Material ............ If yes,type............... ............ <br /> (Plot pion, showing size of lot, location of system In relation to wells, buildings, etc. must be placed on revers side.] <br /> NEW INSTALLATION: iNo septic tank or seepage pit permitted If public sewer Is available within 200 feet,), S� <br /> PACKAGE TREATMENT [ ] SEPTIC TANK I j Size.................................. ............. Liquid Depth ......................... <br /> Capacity .................... Type .................... Material...................... No. Compartments .....................aO <br />'E Distance to nearest: Well ....................... ............Foundatlon ...................... Prop. Lime ...................... <br /> LEACHING LINE ] No. of Linea ........................ Length':of each line....... Total Length ........_................ <br /> 'D' Box ............ Type Filter Matterial ....................Depth :Filter Material ............................................ <br /> fi --Distance to nearest: Well .._..- ................ Foundation ........................ Property Line .................... <br /> SEEPAGE PIT [ ) Depth .................. Diameter ................ Number ............................ Rode Filled Yes ❑ No ❑%F <br /> WaterTo61e Depth ................................................Rack Size ................................ <br /> Distance to nearest: Well ........................................Foundation .................... Prop. Line ..................... <br /> REPAIR/ADDITION(Prev, Sanitation Permit dt ....................................... Date ................................. <br /> Septic Tank (Specify Requirements) ................ ., •---.- ......... ... •.. � ... a4............... <br /> r.............,.................. p <br /> Disposal Field (Specify Requirements) .�r. �jr... y . y <br /> ........................................ .. .... ....... ...... .. .... ............... ..................... . .................... <br /> ................... .. .....................•-----.... .._.. .....................I. ... ......._................ <br /> ......... <br /> .......... <br /> ............ <br /> (Draw existing and required addition on reverse side( <br /> I 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 Joaq,uill Local Heahh District.Borne owner air Ilcen- <br /> 44* <br /> seri agents signature certifies the following <br /> "1 certify that in the performance of the work for which this permit is issued, b shall cot employ any person lin such ewaner <br /> as to became subject to Workmaes's Com sation laws of California." <br /> Signed .....-- Y ................................. Owner <br /> By .............. ..... . .... .............................................. . 3itle ........................................................................ <br /> (if other t an owned <br /> ' FOR DEPARTMENT usE ONLY <br /> APPLICATION ACCEPTED BY .... .. . ..... ................................................... DATE .q./ � .7. .... <br /> BUILDING PERMIT ISSUE© J... ATE (. . ............ <br /> ADDITIONAL COMMENTS , ...�...... .. ,..1..... �1 .- :../....: ... <br /> i!Y�a,l�i, .............................. ................................................ <br /> . Final Inspection bye ................. �........ ...............................................................Date.............................. .. .... ... ...... <br /> E1 13 24 1-60 Rev. SAN JOAQUIN LOCAL HEALTH DISTRICT 874 3H <br />