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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> ------------- - - ------------------------------------ <br /> Permit No. _4�i-__J(30, <br /> "._ (Completein Triplicate) <br /> ---- -------------- ------------------------------------ _ r , . <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 compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOC N .b- O ------ ------ - - 1?4:---- -----------------------CENSUS TRACT ------- ------ - ------- <br /> Owner's Na�mje� -- ----------------� `----- -�=------------------- - ---------qi, Phone <br /> Address T '"' r City ------ = � ` ------------------- ------------------_--- <br /> - <br /> Contractor's Name = -.License # L _r --Phone <br /> Installation will serve: Residence Apartment House❑ Commercial :❑Trailer Court ;❑ <br /> Motel ❑ Other ---------------------------------------- <br /> Number of living units:--.- ------ Number of bedrooms 3--_---Garbage Grinder ------------ Lot Size ------------------------ ------------------ - <br /> Water Supply: Public System and name ------------------------------------------------ ----------------------------=----------------•---------------Private <br /> Character of soil to a depth of 3 feet: Sand❑ it E] Clay E] Peat E] Sandy Loam ❑ Clay Loam ❑ <br /> t , <br /> Hardpan Adobe-E] 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 seep ge pit permitted i f ublic sewer is available-Within 200 feet,) j <br /> SEPTIC TANK' Size- 1(' Liquid De =th -- -------------------- <br /> Ca <br /> ------------------- I <br /> PACKAGE TREATMENT [ [� q -------x-`5------------ P <br /> Capacity l i d- --- Type ______________�_-- Material---- ..-= No. Compartments - ............. Q <br /> " <br /> 'Distance to neares Well -----------x------------------------Foundation ------I-Q----------- Prop. Line ---5_- <br /> LEACHING L14 )rr-,"No. 'of Lines -----/---------------- Length of each line------- ------ Total Length ----14�t_v_.�-_-----.. <br /> 4 'D' Box .`k sl__ Type Filter Material ----- .-_-_Depth Filter Material ------- <br /> Distance to nearest: Well -------SO-_/------ Foundation ---------/A--- ---- Property Line --------- .......... <br /> SEEPAGE PIT [ Depth -------4)--S----- Diameter ----�3__----- Number ----_--..--I-------------- Rock Filled Yes '[� o <br /> o .. <br /> Water Table Depth --------------- 6°--------------- Rock Size ----I-/? x=3{ r <br /> s <br /> Distance-to nearest:Weld -----X1.0-�------------------Foundation ---- Prop. Line ...................... <br /> I <br /> REPAIR/ADDITION,(Prev. Sanitation Permit# -------------------------------------------- Date -----------------------------.-._-) <br /> Septic Tank (Specify Requirements) ---------------------------------------------------------------------------------- --------- ------ <br /> Disposal Field,(Specify Requirements) ----------------------------.-.------------------------------------------------------------------------------------------------------ <br /> --------------------------------------------------------------------------------------- ------------------------------------ <br /> ------------------------------------------------------------------------------ <br /> -------------- ----- ----- --- ----------- - <br /> --- --------------------- -------------------------------------------------------------------------------------------- i <br /> 1 — {Draw existing and required addition on reverse side) <br /> I hereby certify that I have prepared this application..9nd that the work will be done in accordance with San Joaquin <br /> County Ordinances, State Laws;'and Rules and Reguhtions of the San Joaquin Local Health District. Home owner or licen- <br /> sed agents signature certifies the following: I <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 becom s ject to Workman's Compensation laws of California." <br /> i l <br /> Signed ---- ------ -- Owner <br /> BY -- ---------- <br /> ---- <br /> Title ` •-u ------------------------------------ <br /> (If other than owner) <br /> FOR I;?EPARTMENT USE ONLY <br /> s -- - pp <br /> APPLICATION ACCEPTED BY - -1 --- ---------- --------------- DATE -------------------- <br /> BUILDING PERMIT ISSUED ------------------------------ -DATE ------------------------- ------------ <br /> ADDITIONAL COMMENTS -----------------------------------'� ---- - <br /> --------------------------------------------------------- --------------------"-------------------- <br /> -------------------------------------------------- --------------------E --------------`-------------------------------------------------------------------- --- -. <br /> ------------------- - ------- -------------` =l'., Date f_ --- - ---- <br /> Final inspection by: - - ------------------------------------`t r r� �� <br /> G <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H. 9 1-'6$ Rev. 5M <br />