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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> c3 <br /> l (Complete in Triplicate) Permit No. Z:.... ......... <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 andinstall the work herein <br /> described. This application is made in compliance with County Ordinance No. 549 and existing RulesTMand Regulations: <br /> JOB ADDRESS/LOCATION ,. }. 1�.�- s.:. f ,o- ... ------------ --- ---••-....... ........CENSUS TRACT ........................ <br /> Owner's Name <br /> W. 67. -�� Phone 2 aZ— <br /> Address _... f� ...d..y._...., .....` --•...City .." , r--�i.................................. <br /> -... .... <br /> Contractor's Name .. ........ /.�... f�.G i�--s ....----•---------------license # Phone <br /> Installation will serve: a sidence Apartment House❑ Commercial❑Trailer Court 0 <br /> Motel ❑Other ............................................ <br /> Number of living units:...-.f.... Number of bedrooms ..........Garbage Grinder ............ Lot Size ....... Jr -....... <br /> Water Supply: Public System and name .......................................................................................................s:.....Private <br /> Character of soil to a depth of 3 feet: Sand'❑' Silt❑ Clay ❑ Peat C) Sandy Loam 0 Clay itoam ❑ <br /> Hardpan❑ Adobe[] Fill Material ............ If yes,type............................ <br /> (Plot plan, showing lize of lot, location ofsystem in relation to wells, l uildings, 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 f ) Size................................................ Liquid Depth .......................... <br /> m <br /> Capacity l<6.�..... TYPe , Material No. Compartments ............ . <br /> Distance to nearest: Well ........ ....................Foundation / ........ Prop. Line <br /> LEACHING LINE [ ] No. of Lines .....; .............. Length of each line....... ........... Total >..-.......................... O <br /> 'D' Box .4.* Type Filter Material 0?"z-......Depth Filter Material ' ............................. <br /> Distance to nearest: Well .......5�.�.......... Foundation ....a R............ Property Line ...:5................. <br /> SEEPAGE PIT [ ) Depth .................... Diameter ................ Number ............................ Rock Filled -Yas ❑ No C3 <br /> Water Table Depth .....Rock Size 17 <br /> Distance to nearest: Well . .. ... .. <br /> .......................Foundation ..._................ Prop. Line ................... .� <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ............................................ Date .............. ...................) <br /> Septic Tank (Specify Requirements) ..... ........................_......,......................... <br /> Disposal Field (Specify Requirements) .................................•••............................••---••-•••-•--...•••---••------••-•............------......----•-... <br /> •-------•----•.................•-------•-...•----.......•-•••---•••-•-•-•----••••-••---••-•..........-••••--••-•••-•••-•-••-------...•-••-...--•----••-•••--•--•••••••.........--......................... <br /> •----••-------- ---•..................•-...---....•--•-----------•-•---...------------•-------------. ...._---.........................------•--...........---- ....................................... <br /> (Draw existing and required addition on reverse side) <br /> 1 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, 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 ...............W,41. ... . .... .. ............................................. Title ................................... .................................... <br /> (If other than owner) <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ................. DATE .....LA:n� .. S <br /> BUILDING PERMIT ISSUED ......_.....••-•.•-•--•................DATE ........................................... <br /> ADDITIONALCOMMENTS .................................................................._..........----•--•---..............................................................._...... <br /> ...............•-•---•-•-----.........................................---............................................................................................----...............-•--.............. <br /> ...................................................... ................ ...........................---•--............................................. ........... <br /> .. .. ..... ........................................................ .......... <br /> FinalInspectjont-:. :.... ...... . ...... ............ ........._.................................................Date .... . . .... . ......... ......... <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. H.13 241.'68 Rev. 5M .. 7/72 3 M <br />