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FOR OFFIC'F.U3&y APPLICATION FOR SANITATION PERMIT <br /> ................. ------------ Permit No. O <br /> iComplete In Triplicate! .... <br /> ---------------- This Permit Expires I Year From Date issued Date issued . 7,S <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 ma in compliance :t aunty Ordinan No. 549 and existing Ruffs and Regulations: <br /> JOB ADDRESS/LOCTIION f A. .. _... '.. ..... ......................CENSUS TRACT .... ;. ........... <br /> Owner's Name . . I✓ `............................................................. Phone <br /> Address 7-� _ ]- City <br /> .... ............ .. <br /> ................ <br /> Contractor's Name ... ... ._-- _ �OAportment <br /> r .......................License # �.3.�. .. ' Phonet. <br /> Installation will serve: ResidencHousef] 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 ❑ <br /> Character of soil to a depth of 3 feet: Sand❑ Silt❑ Gay ❑ feat❑ Sandy Loan ❑ 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 tide.) <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..............J..,.9�. ------. _........ Liquid Depth ....:.1,�.CC................. <br /> CapacityTy ... Material No. Compartments_- . <br /> � ......_.. <br /> Distance to nearest: We1h1.0_a.......................Foundation .....119.......... Prop, Line .....L O.......... <br /> LEACHING LINT: [ ] No. of. Llnes--.__._�..------ Length of each line....... Total Length ....I..7d........... <br /> D' Box . . Type Filter Ma#eriai . ..... Depth Filter Material .....1.. ............................J <br /> Distance to.nearest. Well .._ ______....��F''o''undation ..... .12........... Property Line --. .r ............. <br /> SEEPAGE PIT [ ) Depth -_,31P----------- Diameter Number .....2-.........�. Rock Filled Yes ❑ No 0 <br /> ..,_...�_ Water Table Depth ---------------------...........................Rock Size ._.I... ... <br /> A rn <br /> Distance to nearest: Well ........................................Foundation ..-----..-----_--- Prop. Line ......I............... ' <br /> REPAIR/ADDITION Wrev. Sanitation permit# .............................---- ------ Date .----------- ._.__..--.....A <br /> Septic Tank (Specify Requirements) ------------------------------------------------------- •---------------• .............. a <br /> Disposal Field (Specify Requirements) .......................... <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 .toaquin Local Health District. Home owner or ilcen 4 <br /> sed agents signature certifies the following: l6 <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 /> Signed ------. - - -- ------- .......... ... . ..... K. Owner <br /> SY .... ---_� `_n -C. - Title _...... r .__... <br /> (f other than ow r <br /> F DEP TMENT USE ONLY <br /> APPLICATION ACCEPTED <br /> BY _. ... ---------- D'ATE - 75— <br /> _.. <br /> BUILDING PERMIT 155UED DATE <br /> -------------- <br /> ADDI <br /> TIONAL COMMENTS -------•--------- -------------- <br /> ---------------------- <br /> ---------------------------------- ------------- ....... 4, <br /> --------- .. .......... .. . <br /> Final Inspection by: -------- ------Date _....... <br /> EH 13 2!t 1-613 Rev. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M <br /> ... 9 <br />