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FOR OFFICE USE: <br /> APPLICATION ICOR SANITATION PERMIT <br /> .................. <br /> lComplete.in Triplicate} Permit No. . ................... <br /> This Permit Expires 1 Year Froni Date Issued. 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/LOCA N W........ - /L��� ......................CENSUS TRACT .......................... <br /> o p � <br /> Owner's Name ...-... ---- - --—^r �.. ................................. ..... �j Phone ......... .......................... <br /> Address . � ...... --.. -- ,: City ...G� .. . . ...................... <br /> Contractor's Name .......:.........License # )e ......... Phone ...... <br /> Installation will serve: Residence Q(Apartment House Commercial❑Traller Court1 <br /> Motel ❑Other__'-. .. .. . . .... <br /> Number of living units:..... ----- Number of bedroom's ... `—� <br /> ...�.a....Garba a Grinder ............ Lot Size ...............':.....,�:-:........ <br /> Water Supply: Pubic System and name ----------•-•....•-•.................----------..:_------• •._....... ......:...:{..:.........:.........:..Private of <br /> Character of soli too depth of 3 feet: Sand❑ Plto Clay ❑ Peat❑ - Sandy Loam ❑ Clay Loam ❑ <br /> x. <br /> Hardpan Adobe ❑ FIII Material ............ if yes,tyke:.............. ............ <br /> (Plot pian, 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 seepa a pit permitted if ublic sewer is available within 200 feet,) , } <br /> PACKAGE TREATMENT [ ] SEPTIC TANK Size.�i� J. J.............. Liquid Depth ... .................r <br /> Capacity ------ Type F4/__ : Material.fi� No. . Compartments -.�. .................0 <br /> Distance to nearest. Well - 0. - ........... <br /> ' -------------• - - -•--..........Foundation ....�.C�: ---- Prop. Line ...:�::.� N <br /> LEACHING LINE No. of LinesLength._ each line--P....14�. ........... Total Length .. �' ............ <br /> [ - -•� ----_--.- of e z <br /> V. Sox .... ...... Type Filter Material .... .......Depth Filter Material...../R............ .. .. <br /> Distance to nearest: Well ... Foundation _.....L.�J..I[. -.... Property Line ...... ....� <br /> SEEPAGE PIT [ Depth Diameter .... ._'_. Number .---..... ...----..... Rock Filled Yes ar'NO I❑s <br /> Water Table Depth •------- ...............Rork Size --.......--- <br /> Distance to nearest: Well ........ t--& ............Foundation Prop. Line ....5..1...... <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ........._-------- ---•.....................Date ..................................... <br /> SepticTank (Specify Requirements)....:..............................................................................................:........................................... <br /> Disposal Field (Specify Requirements) ............................................................................................................................... <br /> ......-. <br /> ............. ........... ----------------------- ------------------------------- --------------------------------------------=-----------------•--•--•••--•--- ••-•----•• ............ <br /> (Draw existing and required addition on reverse side) <br /> I :hereby certify that 1 have prepared this application and that the work.will be done In accordance with.Sart Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the 'San Joaquin Local Health,District. Horne owner or licen. <br /> sed agents signature certifies the following: <br /> "I certify that in the performance of the work far"which this permit Is issued, I sholl not employ any person In such manner <br /> as .to become subject to Workman's Compensation laws of California." <br /> Signed --------•---- ---------------------------------.............................•-•------------------- Owner <br /> By ..---.-- •--------•--..-.... �itie <br /> -----------------•-•• . ............. ............................... <br /> (lf other than owner) <br /> _ FOR DEPARTMENT USE ONLY _ <br /> APPLICATION ACCEPTED BY - ------- --------- -- -- . .. ............ .DATE. . . - <br /> BUILDING PERMIT ISSUED .......- --• ---------------- •-- ----------------------•--------------------- --.----DATE ...------.-----•---------.-- <br /> ADDITIONALCOMMENTS -------------------------- •------- -•----------------------------_..------------------------------_---..............----------...........---....-...- <br /> --------------- --- -- .. --......_....---------•-_------...-------.....------....------------..-.:.....-•............ ....... ------......................... <br /> ---- ---- <br /> ............................... . . <br /> Final inspection by. ... . f__ ... ...... - - - •--•----•-Date . �...........................-- <br /> Ei 13.2h 1--68 ilev. SAN JOAQUIN LOCAL HEALTH DISTRICT 8/7h 3M <br />