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FOR OFFICE USE: <br /> APPLICATION,FOR,,SANITATION PERMIT .� � $ � <br /> (Complete in Triplicate) <br /> Permit No, _________ ___ __ <br /> y ___________ This Permit Expires 1 Year From 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 Ordirbpnce No. 549 and <br /> exiis ing Rules and Regulations: <br /> � . " "`�--r ENSUS TRACT -----------------•----- <br /> JOB ADDRESS ATION .�-� >-3/- - - - - - ----------------- - = - ---------T- -- <br /> Owner's Na _- - - --- --- --- -----•"-- Phone <br /> ---- ----- --------------------- <br /> Address ------- 7! x ------ ----------- - City <br /> Contractor's Name -- ---r ---------------License # -_---------------------- Phone --------------- _- <br /> Installation will serve: Residence Apartment House]] Commercial :❑Trailer Court '❑ <br /> Motel ❑Other -------------------------------------------- <br /> Number of living units------------- Number of bedrooms __J- g-----Garba e Grinder___- Lot Size _ ___ACS _._- t------------- <br /> WaterSupply: Public System and name --------------------------••------------------ --------------------------------------------------------------Private <br /> Character of soil to a depth of 3 feet: Sand'❑ Silt Clay ❑ Peat❑ Sandy Loam ❑ Clay Loam <br /> Hardpan (t]— 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 /> vl <br /> PACKAGE TREATMENT [ ] SEPTIC TANK'jjr) Size_ ------------------ Liquid Depth __! __________________ <br /> Capacity __;-_0_P------- Typek%A_Ar4=_-------- Material---- No. Compartments _i�n--------------- <br /> -� <br /> Distance to nearest: Well ___a-f0--______-_________-_____Foundation ./_�_-__________ Prop. Line __ 7______________• �T <br /> LEACHING LINE DV No. of Lines --- f <br /> "_______________ Length of each line-----��_______________ Total Length -_��_...___.__. _ <br /> 'D' Box Type Filter Material _-- --__--_Depth Filter Material ----- ---------------------------------- <br /> Distance to nearest: Well ---Sw{________"-__ Foundation �P/ <br /> _________________ Property Line S-1___________._____ <br /> SEEPAGE PIT (,'�] Depth _X_=7-r________ Diameter '43/--------- Number ---i'-^------------------- Rock Filled Yes.E] No i❑ <br /> Water Table Depth ----- - -e-----------------------------Rock Size __/�_`'-Jr_____-- <br /> -- ----- <br /> ,�. < 7 <br /> Distance to nearest: Well ----- - Foundation .17---- Prop. Line J---------­------- <br /> REPAIR/ADDITION(Prev. Sanitation Permit# -------_------------------------------------ Date __________________________________) <br /> SepticTank (Specify Requirements) -------- ------------------------------ ------------------------------------ -----------------------------••-----------------------••-- <br /> Disposal Field (Specify Requirements) _�--------------- ------------------------------------------------------- --------------- <br /> --------------------------------= ---- _ <br /> - -- ----------------- - -- ----- - - -------------------------------------------------- ------------------- <br /> - ---------------------- <br /> "jDraw 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: 1 <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 b9c,9me subject toorkm n's ensation laws of California." <br /> Signed '7`_• . _ Owner <br /> - --------------------- ----------------------------------- - <br /> By -- -------- ----------------------------------------------------------------------------- Title ---------------------- ------------------------------------------------- <br /> (If other than owner) <br /> F` FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY i ----- - --------------------- DATE -_% /--- <br /> BUILDING PERMIT ISSUED ---------------DATE ------------------------------------------- <br /> ADDITIONAL COMMENTS <br /> ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- <br /> ----------------------------------------------------------------------------------------------------------------------- ------ <br /> ----------------------------------::::: - ---- <br /> -------- ------------- - - - - <br /> ------------------------------- - ------------------ ---------- ---- ------ <br /> Final Inspection by: <br /> __-_-- Date __-- _-- <br /> ------ <br /> SAN JOAQUIN LOCA"HEALTH DISTRICT <br /> E. H. 9 1-'66 Rev. 5M <br />