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FOR OFFICVUSE- <br /> APPLICATION FOR SANITATION PERMIT <br /> Pe <br /> (Complete in Triplicate) Permit No, 17- <br /> --------------- This Permit Expires 1 Year From Date Issued Date Issued --- <br /> Application is hereby made to the Son 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 /> JOB ADDRESS/LOCATION llrr(�l-----r /I /V, <br /> (2,q <br /> ------------------ - --------------CENSUS TRACT -------------------------- <br /> Owner's Name ----- ---IC5 ---------------------- Phone <br /> Address ------ City <br /> - <br /> Contractor's Name ------- ------ ------- -- ----- -- ----xr License Phone <br /> ----------------- <br /> Installation will serve. Residence;kApartment House-E] Commercial MTrailer Court <br /> Motel [] Other -------------------------------------------- <br /> Number of living units:--_/---- Number of be <br /> ,qrooms _______Garbage GrinderedO' --- Lot Size ..4Z_:aa______ <br /> Water Supply: Public System and name ------41'r --------- ---------------------------------------Private J!k-- <br /> Character of soil to a depth of 3 feet: Sand'E] Silt E] Clay E] Peat El Sandy Loam -0 Clay Loam 0 <br /> Hardpan E] Adobe Lk 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 public sewer is available within 200 feet,] <br /> PACKAGE TREATMENT SEPTIC TANK* Size S-Ze'__k_z-�- -- <br /> --- ------- Liquid Depth --- <br /> Capacity,44-ac---------Type)1410_�._-Materia I No. Compartments ------ - <br /> Distance to nearest: Well .........T-_47---/---------------Foundation ___/a------------ Prop. Line ----- ....... <br /> LEACHING LINE No. of Lines ------0-2------------- Length of each line____.___ 'S-- --------- Total Length _A,�---- --------- <br /> 'D' Box .__f----- Type Filter Material Depth Filter Material ----- ------------- ----------- <br /> ------- <br /> Distance to nearest: Well ---'�XV__/-------- Foundation ---------C---r----"- Property Line ----6----------------- <br /> J_ 7 <br /> SEEPAGE PIT [),r Depth - --cs---------- Diameter Number ------Or----------------- Rock Filled Yes Jr No 0 <br /> Water Table Depth ------ pe:31 - <br /> ----------__--__________________________Rock Size ----ZZ-_re- <br /> -------------------- <br /> Distance to nearest. Well' ---------------------Foundation --gip_--------- Prop. Line ........... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ________-____________________-____) <br /> SepticTank (Specify Requirements) ------------------- ----------------------------------------------------------------------- -------------------------------------------- <br /> DisposalField (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 he 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 follovving-: <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 ----------------------- - Owner- <br /> By <br /> ----------------- <br /> ----- ell- <br /> 1-4 ------------ Title ---- -----C:-----�_V <br /> (If other than owner) <br /> A _J_QR DEPARTMENT USE ONLY <br /> 01 <br /> APPLICATION ACCEPTED BY ------- <br /> BUILDING PERMIT ISSUED ------------ e,_1-�_ ------------------------------------------- DATE -------—--------- -- ---------- <br /> --------------------------------/------------------------ - ------ -----------------------------DATE ------------------------------------------- <br /> ADDITIONAL COMMENTS <br /> - --------- ----------------------------------------------------------- ---------------------- <br /> ------------- - --------------- ---- ------::::------ <br /> ------------------------ ------------- -------- - -- ---- ------- ---------------------- -------------- __1 <br /> ------------------------------------------------------- ---- - ---- - -------- --------------------------------------------------------------- ----------------------- <br /> - - -- ------ <br /> Final Inspection by: ------ - -------- ------ <br /> --- -- ----------------------------------------Dot --- ---------------- <br /> e� ------ X/ <br /> ZN qJOAUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'68 Rev. 5M <br />