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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> ........... ...__.....-...-----• --- --..._.. Permit No. ...-�.�'�/3 <br /> (Complete In Triplicate) <br /> `1 This Permit Expires 1 Year From Date Issued Date Issued ..7...? <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 /> yz,� '`........ . .. .. ......:CENSUS TRACT :.: . ..... <br /> JOB ADDRESS/LOCATION .....l../1�(__.. -.G ......a4z .. .. . <br /> Owner's Name .�.4 f� B .............................Phone .................................... <br /> Address . ....... -r � ... ......... rCity'......... ......•----•-------.............. ... ......... <br /> ..--- .. <br /> Contractor's Name .......fJ ...t p . ..4- 6• ---.----•--•...........License # .........,.... ...._ Phone ........, <br /> Installation will serve: Residence ErApartment House❑ Commercial ❑Trailer Court 0 <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❑ Clay ❑ Peat❑ Sandy loam 0 Clay Loam 0 <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.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,► <br /> PACKAGE TREATMENT [ ] SEPTIC TANK.[ ] Size................................................ Liquid Depth .......................... <br /> Capacity .................... Type .................... Material......------------.... No. Compartments ...................... <br /> Distance to nearest:,Well ....................................Foundation ...................... Prop. Line ...................... <br /> LEACHING LINE [ ] No. of Lines ........................ Length of each line............................ Total Length ............................ <br /> 'D' Box ..------,... Type Filter Material ....................Depth Filter Material .................................:. <br /> Distance to nearest: Well ........................ Foundation .... ................... Property Line ............... � <br /> Depthx10.)V. a .. <br /> Diameter ................ Number ... ............... ... Rock Filled Yes Na <br /> Water Table Depth .........................Rock Size <br /> Distance to nearest: Well ........................................Foundation .................... Prop. Line ...................... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ............................................ Date .................................. <br /> SepticTank (Specify Requirements) .............../..`... ••---......`....•--......_._.._.._............................._...................---...---... ........ ....... <br /> Disposal Field (Specify Requirements) ` o.;.� ..... 't t«�'`- �'` '�� ���3J• <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 Joaquin Local Health District. Home owner or licen- <br /> sed agents signature certifies the following: <br /> "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner <br /> as to become subject to Workman's Compensation laws of California." <br /> Signe4—.... ./er <br /> ... -- •-•---..--•................... Owner <br /> By --- .... .'�".'z`'`.� ............................... Title .......................................... ........................ <br /> (If ofthdn owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY .......: ............... ........................... DATE ..%.:�a..7?.................... <br /> BUILDINGPERMIT ISSUED -•-••.....................................................................................................DATE ........................................... <br /> ADDITIONALCOMMENTS .............................................................•----_........................................•---....-•-•-........ <br /> ..---•.............•---.......-----•---..............---.........------...---•- ..._. .. ....•......----......-...... ...... <br /> ................... <br /> ...... ......... <br /> ...........................••-•----...__............ ............:.. .. _........ ....... <br /> --- - --••�•--•-----•............................................ ........ <br /> Final Inspection by: .-.. .. .. .................................................................Qate ..., ...1.r' .. <br /> SAN J AQUIN LOCAL HEALTH DISTRICT <br /> E. H.13 241_'68 Rev. 5M 7/72 3 M <br />