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FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT 7* <br /> Permit No. <br /> ............. <br /> (Complete in Triplicate) <br /> ....................................................... I. <br /> This Permit Expires 1 Year from Date Issued <br /> Date Issued <br /> ........•............................................... <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 mode in compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATIO/N�y.�..t I ..7`, .__._....... ..............................................CENSUS TRACT --_---------_---------•- <br /> Owner's Name ----- .. ....._...9?'•`• P1 k.s.---•-•.-•................... : ...................Phone --_------------------- ----------- <br /> Address ..._..._. 2� .3 _......__. � lL`'Lr,'u�l ---•--_-------- -------City -••--------------------------------------------------------------------- <br /> Contractor's Name ------------ .................................................. ;IE -- Phone ----- ------- ---------_----- <br /> Installation will serve: Residence❑Apartment House�UCommerciol❑Trailer Court [r] <br /> Motel O Other------ •--•------------ ------------_------ <br /> Number of living units------------- Number of bedrooms -_•.........Garbage Grinder ...._ ...... Lot Size _.....----.----------..-------.------•------ <br /> Water Supply: Public System and name ....................-........................—--------------------.. -_-.. -.-..------------Private 0 <br /> Character of soil to a depth of 3 feet: Sand=1 Silt[] Clay ❑ Peat❑ Sandy Loam 0 Clay Loam ❑ <br /> Hardpan❑ Adobe 0 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 [ I SEPTIC TANK 1 ] Size........................................._.--.... liquid Depth ---------.-_---•-------- - <br /> Capacity -------•---•-- -•- Type --------------•---.. Material--- ........._.....-.. No. .Compartments ...................... " <br /> Distance to nearest: Well ---------------- ------------------Foundation ...................... Prop. Line ------------------_- r <br /> LEACHING LINE [ l No. of Lines ........................ Length of each line............................ Total Length ............................ 0 <br /> 'D' Box ............ Type Filter Material ....................Depthfilter Material .................................. <br /> ........_. <br /> Distance to nearest: Well ------ ................. Foundation- -----------------_------ Property Line .... ........... <br /> SEEPAGE PIT [ ] Depth . Diameter ................ Number .............................. Rock Filled Yes ❑ No <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 - _ -------,l--Q--...--- �-- -•••-•.,¢�f[_!!/.ts-------------------• ............... <br /> ---•------------------------------ ---------------------------------- ----------•- --------- -------•-•• -------- ---• -----• ---------------- .....---....-------- <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 HeaI&District. Home owner or licen- <br /> sed agents signature certifies the following: <br /> "1 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 t Wolk—man's pensation laws of California." <br /> Signe,d/>0 ----------------------------------------------------------- Owner <br /> ......................................----------------------------------- Title ------------.....----- ......................... <br /> (If other than owner) <br /> FO DE!&TMgNT7 USE ONLY <br /> APPLICATION ACCEPTED BY .._61110DATE <br /> -- --- •-•••--•---------._.. DATE ....�.- ...`-- - ------ -------- <br /> BUILDING PERMIT ISSUED ._.__ -.. ..... ....... _--------.......__....... ----------•-•---- <br /> ADDITIONAL COMMENTS ------------------------------ ....................... ......................... <br /> ...........................---• ----------------------------....-------•------ ............--•-.......................................... <br /> c <br /> Final Inspection 6 ...................Date ..... . ..- . l=._7__.......---- <br /> EH .13 2!I 1-68 Rev. 5M SA JOAQUIN LOCAL HEALTH DISTRICT 8/71; 3M <br />